PEMF Interest Form

First Name *

Last Name *

Phone *

Email *

Have you recently received stem cell therapy? *

Yes

No

Where did you get treated for stem cells? (Click all that apply) *

What areas do you have pain? (Click all that apply) *

For any answers "other", please list and describe here

I want to... *

Purchase

Rent

Which Device would you like? *

Which Coil Attachment(s) are you interested in? *

Single Loop

Double Loop

Mat

Paddle

Seat

Helmet

Mailing Street Address *

City *

State *

Country *

Country

Postal code *

Is billing address the same as your shipping address provided? *

Yes

No

If different, please provide billing address *

Upload a photo of your Photo ID *

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF

Anything else you would like to share with the PEMF rep?

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