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Please print out this form, complete the top
portion, have your Health Care
Provider (Medical Doctor, Chiropractor, Dentist, Podiatrist,
Nurse Practitioner, Physicians Assistant, Ph.D., Physical
Therapist, Doctor of Acupuncture or Doctor of Osteopathy)
sign it and mail or fax it in today.
THIS FORM REQUIRED FOR USA ORDERS ONLY!
(Not required for international orders.)
(Please Print)
Patient's Name_______________________________________________________
Address
___________________________________________________________
City ______________________
State _____________________
Zip ___________
Day Phone________________________Evening Phone _____________________
E-mail_____________________________Fax _____________________________
TENS Unit $99.00
Interferential Unit $199.00
EMS 2000R (275) or 4000R (350)
Method of Payment: Check Enclosed (US Currency Only)
Mastercard
Visa
Card #________________________________________Exp. Date _____________
Name on Credit
Card__________________________________________________
Credit Card Billing
Address_________________________________ Zip _________
Signature ________________________________________________________
Name of your licensed health care
practitioner _______________________________
License # __________________________________________________________
Dr's address ________________________________________________________
City_______________________State____________________Zip
____________
Doctor's
Signature __________________________________________________
Print out and mail/fax
form to:
BackSport Health Products
13820 Stowe Dr
Poway, CA 92064
Toll Free FAX: (888) 280-0299 or (858) 218-1321
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