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.

TENS / EMS PRESCRIPTION FORM

THIS FORM REQUIRED FOR USA ORDERS ONLY! (not required for international orders.)

Patient's Name___________________________________________________________

Address _______________________________________________________________

City ________________________ State _______________________ Zip ___________

Day Phone__________________________Evening Phone _______________________

E-mail______________________________Fax ________________________________

Model Ordering: _________________________ Price: ______________

Method of Payment: --- Check Enclosed Mastercard Visa

 

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:

VITALITYWEB.COM, Inc
13820 Stowe Dr
Poway, CA. 92064
FAX: Toll Free to (888) 280-0299 or (858) 218-1321

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