Ex N' Flex Information Request

Ex N' Flex Information Request
How Can We help You? *
How did your hear about us?
Would you like us to call you to discuss your requirements?

Yes No
When would you like us to call you?

Morning Afternoon Evening
What Day(s) are best for you?

Monday Tuesday Wednesday Thursday Friday Saturday Sunday
Name *

First Name Last Name
Facility or Organization
E-mail *
Phone Number *

Area Code Phone Number
Address

Street Address

Street Address Line 2

City
Postal/ZIP Code *

Street Address

Street Address Line 2
Province/State *

Street Address

Street Address Line 2
Country *

Street Address

Street Address Line 2
Are you a ....?

Current Ex N' Flex User Care Giver Spouse/Family Member Friend
What is your Profession? *

Healthcare/Disability Professional Dealer/Distributor Association Representative Other
What Ex N' Flex Product are you interested in? *

EF-250 Leg Therapy Machine EF-300 Arm/Leg Therapy machine EF-100 Arm/Wrist Therapy machine
My intent is to ... *

Purchase Immediately Purchase in the next 30 days Purchase in the next 30-60 days Purchase in the next 3-6 months Purchase at some point in the future Gather information about the Ex N' Flex product line
Consumer Finance

I am interested in your Consumer Finance Plan
Additional Information
Would you like to receive email/newsletter information from us in the future? (You can unsubscribe at any time)

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Please verify that you are human *
Form ID
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