Neurolief

Welcome to the
Relivion®MG 60-Day
Trial Program!
Your health and privacy are of utmost importance to us, and your information will be collected and processed in accordance with our privacy practices as detailed in our Privacy Policy.

Before you proceed, we kindly ask for your consent to use your health-related information to participate in the Relivion trial program. Rest assured, we strictly adhere to all applicable laws and regulations to safeguard your data.

If you have any questions or concerns regarding your privacy or the trial program, please don't hesitate to contact us.

Contraindications

Please review and confirm you do not have any of the following. Please note the Relivion device is worn on the head and can fit a maximum circumference of 23.5 inches (600mm). We have found that people who wear XXL hats are not able to wear the device.
All check boxes are mandatory*

I do not have a metal implant or shrapnel in my head (dental implants are OK)I do not have recent (less than three months) brain or facial traumaI do not have skin abrasions on the forehead or occiput – these are contact areas of the Relivion MGI do not have an implanted neurostimulator or any implanted metallic or electronic device in the head, a cardiac pacemaker or an implanted or wearable defibrillator

Patient Details

Please fill out the below information.
First Name*
Last Name*
Mobile Phone*
(XXX)XXX-XXXX
Email*
example@example.com
Please note: We are unable to ship to PO Boxes or the following states: Michigan, Mississippi, Montana, Nevada, New Mexico, North Dakota, and Tennessee due to local regulations. We apologize for the inconvenience.
Delivery Address*

CityState / Province

Postal / Zip Code
City*
State*
Zip Code*
SMS Opt-in For Ongoing Support. Message and data rates may apply. Messaging frequency may vary. See our Privacy Policy and Terms and Conditions for more information.*

I agree to receive SMS notifications regarding my device, treatment, and account information. I understand I can opt out at any time by replying "STOP" or contacting customer support. I can also reply "HELP" for support.I do not wish to opt-in and all I will be responsible for all communications with the support team. For assistance, reach out to support@relivion-medical.com
Terms & Conditions: Please read and scroll to the bottom to enable the checkbox.*

Payment

Relivion® MG 60-Day TrialThese first 60 days will set the foundation for your success with Relivion, and we are here to help you meet your treatment goals. Includes training, refill pads, and access to exclusive Relivion resources. Purchase options available once trial is completed.

$200.00

Total

$0.00

Credit Card

First Name

Last Name

Card Number

Security Code

Expiration Month

Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Should be Empty:

Contraindications

Patient Details

Payment