New Customer safety check

1

Please enter your emailThis is so we can identify your interest

example@example.com

2

Do you have a long term condition or long term/recurrent pain* This field is required.(lasting longer than 3 months)

YESNO

3

My pain is: Intense spinal pain, mechanical back pain or NON - MS related nerve pain.* This field is required.

YESNO

4

Full Name* This field is required.

First Name

Last Name

5

Has the pain you wish to treat been investigated?

YESNO

6

What was the cause diagnosed as

7

Can you reach your spine, feet and painful area OR do you have someone help you do so

YESNO

8

Do any of the following relate to you* This field is required.

Epilepsy

Fitted with a heart pace maker

Cancer in the past 5 years

Suffered from a heart attack, stroke, deep vein thrombosis or pulmonary embolus in the past 3 months

Pregnant

None of the above

9

Who did you hear about APS therapy from?