ThermaZone Thermal Therapy Device RENTAL Inquiry

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* 1. Please provide your contact information

First & Last Name

State/Province

Email Address

Phone Number

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* 2. How did you hear about ThermaZone?

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* 3. Physician's name for prescription information (Optional)

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* 4. Physician's phone number (optional)

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* 5. Please provide desired delivery date for the product. Please note that IME will need 5 business days for shipment:

Date / Time

Date

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* 6. Will you be using one of the following:

Self-pay

Private Insurance

Worker's Comp