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

Preferred day/time for contact. Include timezone *

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 *

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 *

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

Any questions or additional notes you would like a PEMF Representative to go over with you before we submit your 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 submitting this form, 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.