TENS/EMS PAIN CONTROL UNITS PRESCRIPTION ORDER FORM
Please print out this form, complete the top portion, have your Health Care Provider (Medical Doctor, Chiropractor, Dentist, Podiatrist, Nurse Practitioner, Physicians Assistant, PH.D., Physical Therapist, Doctor of Acupuncture or Doctor of Osteopathy) sign it and mail or fax it in today. 

TOLL FREE -- FAX 24hrs (800)876-5402 --- PHONE (800)634-0880
Kappa Medical, Inc.  PO Box 11808  Prescott, AZ  86304-1808

THIS FORM REQUIRED FOR USA ORDERS ONLY! (not required for international orders.)
(Please Print)

Patient's Name___________________________________________________________________

Address________________________________________________________________________

City________________________________ State_______________ Zip_____________________

Day Phone_______________________ Evening Phone__________________________________

Email__________________________________ Fax_____________________________________

Check  your choice below:

___________________________  Enter the Model # of the  TENS or EMS unit number here

Shipping for one TENS Unit or One EMS unit is $8.00 via UPS Ground Service
 

Credit Card#_____________________________________________Exp. Date_______________

Name on Credit Card______________________________________________________________

Credit Card Billing Address_____________________________________Zip__________________

Signature_______________________________________________________________________

Name of your licensed health care provider____________________________________________

License#________________________________________________________________________

Dr's address_____________________________________________________________________

City____________________________State_______________ Zip__________________________

Doctor's Signature________________________________________________________________

Print out and mail/fax form