ThermaZone Thermal Therapy Device PRESCRIBING Inquiry

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* 1. Please provide your contact information

First & Last Name

Clinic | Hospital | Organization

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

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* 2. How did you hear about ThermaZone?

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* 3. Type of Facility

Government/Military (ex. VA or DoD)

Physical Therapy Clinic

Hospital

Athletic Training (Professional Sports Team or Collegiate)

Other (please specify)

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* 4. Types of Patients your work with:

Worker's Comp

Private Insurance

No Fault Auto

Other (please specify)

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* 5. How many physicians are in your practice?

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* 6. How many surgeries are performed in your facility each week?

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* 7. How many of your monthly patients are under worker's comp?

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* 8. Can we send you the latest product news, articles, and offers?

Yes

No