Rusk County Electric Cooperative, Inc.
- O. Box 1169
Henderson, TX. 75653
Account Name________________________________ A/C Number______________________
Address_____________________________________ Telephone________________________
___________________________________________
Emergency contact person_________________________________________________________
their telephone___________________________________________________________________
PLEASE HAVE YOUR DOCTOR COMPLETE THIS PART
Patient's name: _______________________________________________________________
Life sustaining electric equipment: _____________________________________________________________________
(i.e., electrically driven oxygen concentrator, nebulizer, suction machine, feeding machine, dialysis machine)
__________________________________ ______________________________________ _______________________
Doctor's name (please print) Signature Date
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