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Forms

PRESCRIPTION ORDER FORM FOR TENS UNITS / EMS / INTERFERENTIALS

Please print out this form, complete the top portion and middle portion (optional), have your Health Care Provider (Chiropractor, Podiatrist, Physical Therapist, Doctor of Osteopathy, Medical Doctor, Dentist, Nurse Practitioner, PH.D., or Doctor of Acupuncture) complete the bottom portion and fax it to:

TOLL FREE FAX- 24 Hours/Day, 7 Days/Week 1 (877) 890-TENS (8367)

 

Patient's Name

 

Unit Name(s)

  ______________________   _______________ Qty ____
       
  Phone  

Card# Exp. Date

  __________________________  

____________________

     

  Address   Name on Credit Card & Signature
  ___________________________   ___________________________
       
  City State Zip   Packs of extra Electrodes, comes with a pack of 4, only $7 per extra pack with purchase of UNIT
  __________________________   __________________________________


 

Name of your licensed health care provider

  City State Zip
 

___________________________________

  __________________________________
       
  Address   Signature
  __________________________________   ___________________________________