Authorized RepresentativeAquex Product Order Form Please enable JavaScript in your browser to complete this form.Patient Name *FirstLastDOB *Mobile PhoneAlternate PhoneEmail *Address *City *State *Zip *Is The Shipping Address Different From the Above Address? *YesNoShipping NameShipping AddressShipping CityShipping StateShipping ZipI prefer to be contacted by: *Voice CallEmailTextProduct Choices (check all that apply)Aquex Tap WaterIontophoresis Basic KitFor treating Hands and FeetUnderarm Treatment KitTwo padess for treatingunderarmsnd ChoiceReplacement TowelsReplacement Padsfor Underarm KitNumber of Pairs of TowelsNumber of Pair of PadsTreatment pads are available for other areas: Face, Stomach, Back, Legs, etc. Please describe other areas that need treatment:ConfirmationI 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 conditionsWho will be signing this order form? *The PatientSomeone ElseRelation To PatientParentAuthorized RepresentativeIf Authorized Representative, Reason patient can't sign:WebsiteSign and submit the Aquex online order Form The encryption, and transmission of this information complies with HIPAA protocols.