Plasmaflow Prescription

Only your doctor can determine if you are at risk for Deep Vein Thrombosis (DVT), a blood clot that forms in one of the deep veins of your legs. A review of your personal history and current health may determine if you are at risk for developing this condition. Take a moment to complete this form for yourself (or complete it for a loved one). Then be sure to talk with your doctor about your risk for DVT and see if the PlasmaFlow is right for you. Your doctor may want to keep a copy in your file for future reference.

Want to Download the Risk Assessment PDF Instead?.

Patient Information


1. Fill out patient information and check all statements that apply to you.

2. View your risk score below that gets automatically calculated.

3. Share this information with your doctor or your doctor can sign and automatically generate an RX below.

Each Risk Factor is 1 Point
Each Risk Factor is 2 Points
Each Risk Factor is 3 Points
Each Risk Factor is 5 Points
For Women Only (1 Point)

Your Risk is Low. You have 0 Point(s).

Anticoagulants: Factors Associated with Increased Bleeding

If any of the below boxes below are checked, the patient may not be a candidate for anticoagulant therapy and you should consider alternative prophylactic measures: elastic stockings and/or IPC.

Intermittent Pneumatic Compression (IPC)

If any of the below boxes are checked, then patient may not be a candidate for intermittent compression therapy and you should consider alternative prophylactic measures.

Order for At-Home DVT Prevention System.

YES, patient qualifies for an At-Home DVT Prevention System to be used by the patient as instructed by the referring physician.

Deep vein Thrombosis (DVT) is a significant risk factor for patients undergoing surgery and immobilized patients. Prevention of DVT is more effective than treatment and an important aspect of patient care before, during and after surgery. I have assessed this patient's risk of developing DVT due to age, type of surgery, patient and family medical history, and other documented factors that may increase the risk of DVT. My assessment indicates the use of mechanical thromboprophylaxis by pneuymatic compression device and segmental gradient pressure pneumatic appliances. It is my opinion this is medically necessary and reasonable in accordance with accepted standards of practice and appropriate treatment of this patient.

The critical post discharge period due to the medical necessity of increasing blood circulation and decreasing postoperative pain, swelling and inflammation. PlasmaFlow mobile compression system received FDA clearance and has proven clinical studies that show it is an effective non pharmacologic therapy for enhancement of blood circulation and or DVT Management. Clinical evidence has shown the PlasmaFlow mobile compression system to be as effective as low molecular weight heparins LMWH and to eliminate the anticoagulants serious bleeding complications. Significant published data is available on the incidents of DVT/PE, the effectiveness of various prophylactic techniques and the risks of hemorrhage when heparin is used, all of which provide positive and compelling evidence in support for the use of intermittent compression devices in VTE prevention.

I have prescribed the above system and certify that the PlasmaFlow mobile compression system device and supplies are medically necessary for the treatment of my patient's care. I have found that the PlasmaFlow mobile compression system improves the healing time and provides reduction of complications following hip or knee arthroplasty. Recovery is quicker and subsequent physical therapy is more effective. The foregoing is per consensus from the guidelines for VTE Prophylaxis from the ACCP (American College of Chest Physicians); recommendations from AAOS (American Academy of Orthopedic Surgeons); and SCIP (Surgical Care Improvement Program).

Submit Risk Assessment to ManaMed