Physician Letter recommending VitalStim Treatment
<Name Physician>
<Address>
<City, State ZIP>
Re: <Name Patient – Medical Record Number>
DOB: <Patient’s Date of Birth>
Date: <Today’s Date>
Dear Dr. <Name Physician>:
I am recommending that your patient, <Name Patient>, receive intensive dysphagia therapy
utilizing transcutaneous pharyngeal and/or facial electrical stimulation during therapy sessions
("VitalStim"). I have received training and documentation in this new dysphagia therapy
technique using the VitalStim unit, which was approved by the FDA in Dec. 2002 for use by
Speech Language Pathologists specifically for the treatment of dysphagia.
This unit is a specially designed neuromuscular electrical stimulation unit similar in look to a
TENS unit, but has one quarter the output with smaller increments of amperage and uses smaller,
specialized electrodes. It is the only unit on the market that is approved by the FDA for use on the
pharyngeal musculature. Through intensive therapy (2-5 sessions per week x 2-3 wks) combining
electrical stimulation and swallowing activities, it has the potential for improving swallowing
function (pharyngeal and oral-facial-dysphagia) and facial function (facial paresis, Bell’s palsy),
thereby decreasing the severity of dysphagia and in most cases eliminating aspiration.
The use of this device during therapy will hopefully enhance <Patient’s Name>'s response and
accelerate progress toward <Patient’s Functional Goal>. Please see my enclosed report for
details. If there is a need for repeated series of treatments to continue to advance swallowing
function, a follow-up Modified Barium Swallow Study will probably be needed to re-assess
swallowing function. I will let you know if any additional medical procedures are suggested to
further advance his/her swallowing skills.
Please also send me a prescription stating "Dysphagia Treatment and Electrical Stimulation
(VitalStim) __ x wk x ___ wks".
Thank you for your time. Please feel free to call me if you have any questions. I look forward to
hearing from you.
Sincerely,
<Name Therapist>, MS, CCC-SLP
Licensed Speech Language Pathologist, #<License Number>