Rental Reservation

Rental Reservation
Name*

First NameLast Name
Email*
example@example.com
Address*

Street Address Line 1

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
Rental Plan:*

Individual (up to 15 sessions) - 1 Month - $600Unlimited (includes supplies for up to 100 sessions) - 1 Month - $900Extended Unlimited (includes supplies for up to 100 sessions) - 2 Months - $1,550
Please let us know if you're ready to rent now (next available system) or specify a date:*
Will we be shipping the system to a residential address?*

YesNo
Promo Code:
How did you hear about us?*
Comments:

Rental Deposit

Rental Deposit (nonrefundable)$50.00

Applied toward total rental cost

Total $0.00