Vitalityweb.com - Herman Miller Office Chairs, Stressless Recliners, Fjords Chairs and Human Touch Massage Chairs

 

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.

 MAIL/FAX ORDER FORM

Yes! I want to stop pain fast. Please send me a T.E.N.S. unit today.

(Please Print)
Patient's Name___________________________________________________________

Address _______________________________________________________________

City ________________________ State _______________________ Zip ___________

Day Phone__________________________Evening Phone _______________________

E-mail______________________________Fax ________________________________

Model Ordering: _____________________________ Price: ___________

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:
The Backstore at Vitalityweb.com
13820 Stowe Dr
Poway, CA 92064

 

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