Medword Medical Equipment Order Form For U.S. Citizens

MEDWORD MEDICAL EQUIPMENT
PRESCRIPTION FORM FOR U.S. CITIZENS
ORDERING TENS, EMS, IF, & GALVANIC UNITS

Please complete the customer portion of the form. Have your health-care provider, for this purpose defined as: Chiropractor, Podiatrist, Physical Therapist, Doctor of Osteopathy, Medical Doctor, Dentist, Nurse Practitioner, PH.D., or Doctor of Acupuncture, complete the provider portion. If your health-care provider needs information on any unit, they can visit the Medword page here: http://www.medword.com/MedwordStore/PCP/index.html

WHEN COMPLETED, PLEASE FAX THIS FORM, 24 HOURS/DAY, 7 DAYS/WEEK
TO THIS TOLL-FREE NUMBER: 1-877-512-3015

CUSTOMER PORTION

Patient Name: Phone:

Address:

City: Province/State:

Postal Code/Zip: Country:

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Unit or Model *Name: Qty:

Extra Electrodes: (Comes with a 4-Pack) Qty: Packs at $9.00 per extra pack

*Names: Arista 2000, Arista EMS Plus, Arista SD Plus, IF-4000, Century 2100, Century 2400, EMS-5000, Microcurrent 850, Pulsed-Galvanic Stimulator, etc.

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Card Card No: Expires: (MM / YYYY)

Name on Credit Card:

Signature:

LICENSED HEALTH-CARE PROVIDER PORTION

Health-Care Provider Name:

Address:

City: Province/State:

Postal Code/Zip: Country:

Signature:

†PLEASE NOTE: Canadian citizens do not require a prescription to order one of these units,
but we strongly advise discussing use of such units with a health-care professional before ordering.