TEST FORM

$60 One-Time Setup Fee (36 month Renewable.)
+
$10 / PP / month (1 month Renewable). (Can be Renewed up to 36 times)

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone(Required)

Email(Required)

$60 One-Time Setup Fee Per Patient(Required)

Price:

Quantity(Required)

Please enter a number greater than or equal to 1.

$10 Monthly Fee per Patient(Required)

Price:

Quantity(Required)

Please enter a number greater than or equal to 1.

Total

Consent(Required)

I understand products will not be shipped until document is signed.

Credit Card(Required)

American Express

Discover

MasterCard

Visa

Card Number

Expiration Date

Security Code Cardholder Name

1-800 GET WELL