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FreeMOM TENS
Labour Pain
Management
COMPACT TENS
Chronic/Acute Pain
Management
FreeLADY
Menstrual/Endometriosis
Pain Management
TENS Accessories
Electrodes, Cables,
Wipes, etc..


Online Hire Application Form

PERSONAL INFORMATION:

First Name
Surname
Address
Suburb
State
Postcode
Telephone No
Mobile No
Email
Maternity Hospital
Private Health Insurance
Provider Name (if applicable)
Private Health Insurance
Member Number (if applicable)
Your Pre-natal Educator
Pharmacy

IMPORTANT DATES:

Application date24/01/2018
Due date
Required date

IMPORTANT The FreeMOM TENS stimulator kit is usually supplied at week 37 to 38 of your pregnancy.


PRODUCTS DETAILS:

Please select item(s) required by ticking the boxes:

 Hire a FreeMOM TENS kit for Labour Pain ManagementAUD
 
 FreeMOM TENS Hire (Incl. GST) - for the term of your confinement$50.00
 Labour Electrodes: - refundable if returned not opened, used or damaged$35.00
 Deposit - refundable on the return of the FreeMOM TENS kit$40.00
 
Postage - Australia Post delivery to your address $15.00
Prepaid return Postage Satchel - Australia post delivery to our office $15.00
 
 If applicable, OPTIONS - refundable if returned not opened, used or damaged 
 
Back Pain or Pelvic Instability Electrodes with Clean-cote Skin Wipes$20.00
 and battery 
 
Neck and Shoulder Pain Electrodes with Clean-cote Skin Wipes and battery$20.00
 
 Total (Inc. GST)$

CREDIT CARD PAYMENT INFORMATION:


Debit or Credit Card
Credit Card Number
Expiry Date /
CVV/CVC

ORDERS ARE DELAYED IF CARD NUMBER, EXPIRY DATE OR CVC NUMBERS ARE INCORRECT. PLEASE DOUBLE CHECK THEM BEFORE CLICKING THE ORDER BUTTON. THANK YOU.

COMMENTS:






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