This form serves as a Standard Written Order and Prescription for the Vivally System for this patient. As this patient’s Prescriber, I attest that the clinical information in this document accurately reflects the patient’s health status and condition. I further certify that the Vivally System is reasonable and medically necessary for the treatment of this patient’s condition. I understand that my email address and a secure login to the Vivally System may be required for me to access Vivally System data for this patient.