Aquex Product Order Form

Patient Name *

First

Last

DOB *

Mobile Phone

Alternate Phone

Email *

Address *

City *

State *

Zip *

Is The Shipping Address Different From the Above Address? *

Shipping Name

Shipping Address

Shipping City

Shipping State

Shipping Zip

I prefer to be contacted by: *

Voice Call
Email
Text

Product Choices (check all that apply)

Aquex Tap Water
Iontophoresis Basic Kit
For treating Hands and Feet
Underarm Treatment Kit
Two padess for treating
underarmsnd Choice
Replacement Towels
Replacement Pads
for Underarm Kit

Number of Pairs of Towels

Number of Pair of Pads

Treatment pads are available for other areas: Face, Stomach, Back, Legs, etc. Please describe other areas that need treatment:

Confirmation

I confirm that the above information is accurate and complete to the best of my knowledge. I agree to follow my prescriber’s instructions for the proper use of this medical device.
It is important to understand the size, weight and electrical requirements of your device. Please discuss these details and any special delivery needs you may have with your Dermitech representative by calling 214-377-8144.

I confirm that I have read, and agree to the Terms And Conditions *

I have read and agree to the terms and conditions

Who will be signing this order form? *

The Patient
Someone Else

Relation To Patient

Parent
Authorized Representative

If Authorized Representative, Reason patient can't sign:

The encryption, and transmission of this information complies with HIPAA protocols.