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.
TOLL FREE -- FAX 24hrs (888) 280-0299 ---- PHONE (888) 293-0728
TENS/EMS PRESCRIPTION FORM
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 $119.00 Plus $6.95 S/H. Express Overnight Shipping is $30
Interferential Unit $199.00 Plus $6.95 S/H. Express Overnight Shipping is $30
EMS 2000R (315.00) or 4000R (425.00) Plus $6.95 S/H. Express Overnight Shipping is $45
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 provider
_____________________________________
License #
______________________________________________________________
Dr's address
____________________________________________________________
City
________________________
State
_______________________
Zip
_____________
Doctor's Signature
_______________________________________________________
Print out and mail/fax form to:
SELFCARESUPPLY.COM
13820 Stowe Dr
Poway, CA. 92064
FAX: Toll Free to (888) 280-0299 or (858) 218-1321
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