EQUIPMENT RENTAL ORDER

QI LIFE WAVE SMART ACUPUNCTURE LEASE FORM

Smart Acupuncture Cushion/Pad/Bundle: 3-month 6-month or 12-month Lease with deposit and Auto-Renewal
Date

MonthDayYear
Click and read the Equipment Lease Agreement. You will be required to consent to the agreement below. Download for your records. Qi Life Wave Smart Acupuncture Lease Form ("Lease Form") is part of the Lease Agreement.
Lessor: TYQA, Inc.

| Lessor address: 1270 6th Ave 8th Floor NY NY 10020 | Lessor email: contact@healthwich.org
Lessee:*

First NameMiddle NameLast Name
Lessee Phone Number:*

Area CodePhone Number
Lessee Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Proof of Payment

Lease Term and Order Number must match the values on your payment receipt to avoid delays in processing your lease.
Lease Term (Select Option)*
Order Number*
For proof of payment enter Order Number from payment receipt or email.
Start Date*

MonthDayYear
Start Date must be greater than Date.
End Date*

MonthDayYear
End Date must be greater than Start Date
Proof of Payment:*

Browse Files
Screenshot your payment slip and attach here: Cancelof
CONTACT US FOR ASSISTANCE:

contact@healthwich.org
TERM & CONDITION:*
Lessee Signature *

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*Sign if you are agree with the term & conditions
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QI LIFE WAVE SMART ACUPUNCTURE LEASE FORM