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Date : ____________________________ Patient Name : ____________________________ CLINICAL DIAGNOSIS: ________________________________________________ Dear Sir, Madam: Following my examination of the above-noted patient, I have determined they suffer from a chronic respiratory ailment. This ailment is exacerbated — among others — by poor indoor air quality, which has an adverse effect on their well-being. To cope with the symptoms of this severe chronic respiratory ailment, I prescribe for this patient the installation of the following product for the purpose of purifying the air in their home: Model Name: • • vänEE THH 1.0 vänEE HEPA 3.2 The unit should be operated according to the manufacturer’s instructions, and the HEPA filter must be replaced annually by the same make and model. Sincerely, _____________________________________, M.D.