|
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 Plus $6.50 S/H. Express Overnight Shipping is $15
Interferential Unit $199.00 Plus $6.50 S/H. Express Overnight Shipping
is $20
EMS 2000R (299.95) or 4000R (399.95) Plus $6.50 S/H. Express Overnight
Shipping is $30
Method of Payment:
Check Enclosed (US Currency Only)
Mastercard
Visa
Discover
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
2333 Camino Del Rio South #230
PO BOX 881701
San Diego, CA. 92168-1701
Toll Free FAX: (888) 280-0299 or (858) 538-7828
|