Ex N' Flex Information Request

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

YesNo
When would you like us to call you?

MorningAfternoonEvening
What Day(s) are best for you?

MondayTuesdayWednesdayThursdayFridaySaturdaySunday
Name*

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

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
City

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Province/State*

Street Address

Street Address Line 2

City

Postal / Zip Code
Postal/ZIP Code*

Street Address

Street Address Line 2

CityState / Province
Country*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Are you a ....?

Current Ex N' Flex UserCare GiverSpouse/Family MemberFriend
What is your Profession?*

Healthcare/Disability ProfessionalDealer/DistributorAssociation RepresentativeOther
What Ex N' Flex Product are you interested in?*

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

Purchase ImmediatelyPurchase in the next 30 daysPurchase in the next 30-60 daysPurchase in the next 3-6 monthsPurchase at some point in the futureGather information about the Ex N' Flex product line
Consumer Finance

I am interested in your Consumer Finance Plan
Health Insurance

I plan to use my Health Insurance for this purchase.
Purchase Support Programs

Do you have MS? You may be able to get a 10% discount on a new EF-250/EF-300Do you have a Spinal Cord injury? United Spinal Association members get a 10% discount on new EF-250s and EF-300s.Are you a veteran? You my qualify for a 10% discount on new EF-250s and EF-300s.
Additional Information
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