Phone: 334-875-2269, Fax: 334-875-2221, Out of state call 1-800-867-3726.
Company Name:
Name:
Phone #:
- -
Address:
City:
State:
Zip:
Visa/Master Card Credit Card:
- - -
Exp. Date:
Is Credit Card bill to address same as above:
Yes
No (List Below)
Name:
Address:
City:
State:
Zip:
How did you hear about us?
Internet
Friend
Store
TV
Radio AM/FM
Mailing/Info Request
Show
Doctor/Physician
Nurse Pratitioner
Physical Therapist
Other
FPT Pricing
$79.99
Standard, Small or Petite
FPT
QTY @
Amount
Standard Unit
$
Small Unit
$
Petite Unit
$
$
$
$
$
$
$
$
Shipping & Handling Via FedEx Ground
$10.00
MPT Clinical Pricings
$109.99
Additional Weights $14.99 each
MPT
QTY @
Amount
Complete Unit
$
Small Disc
$
Larger Disc
$
$
$
$
$
$
$
$
Shipping & Handling Via FedEx Ground
$10.00
Total Amount of This Order:
$
Shipping Note: We will charge you the actual
charges of shipping and no more. If you must know the exact amount you
will need to call before mailing this form. 334-875-2292