TENS/EMS PAIN CONTROL UNITS PRESCRIPTION ORDER FORM

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 (800) 796-9469 ---- PHONE (800) 796-9656

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 $99.00 Plus $6.50 S/H. Express Overnight Shipping is $27
Interferential Stimulator $199.00 Plus $6 S/H. Express Overnight Shipping is $27
EMS 4000R $399.95 Plus $6.50 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:

Building Body Fitness Machines
2333 Camino Del Rio South #230
PO Box 881701
San Diego, CA. 92168
FAX: Toll Free to (800) 796-9469 or (858) 565-7339

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