PEMF Interest Form

First Name *

Last Name *

Phone *

Email *

Have you recently received stem cell therapy? *

Yes

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

What is your current interest level? *

I know which device I want to rent

I know which device I want to purchase

I have more questions I'd like to ask

Which Device would you like?

Which one?

Which Coil Attachment(s) are you interested in?

Single Loop

Double Loop 7"

Double Loop 9"

Mat

Paddle

Seat

Helmet

Street Address

City

State

Country

Postal code

Is billing address the same as your shipping address provided?

Yes

If different, please provide billing address

Upload a photo of your Photo ID

Any questions or additional notes you would like a PEMF Representative to go over with you before we submit your order?

Order Confirmation Call

I acknowledge before proceeding, I will need to schedule a 5 minute order confirmation call with a PEMF specialist to finalize details of my order.

Minimum Term Rental Acknowledgment

I understand the minimum rental term is 2 months.

Purchase Credit Acknowledgement

If I decide to purchase this rental, up to 3 rental payments will be applied to the purchase price of the unit I’m renting.

Shipping acknowledgment

After your order confirmation you will receive a rental agreement within 24 hours that would need to be signed. By checking this box I understand my order will not be submitted or shipped until MHF receives my signed Rental Agreement, first month’s payment, and a copy of my driver’s license.. Once this is completed, your order will be submitted and you will receive shipping tracking information within 2-3 business days. Signature is required upon delivery.