Online Orders | Ampcare ESP

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Date

Purchase Order (if applicable)

Certification Number or Therapist's Name

Your Ampcare Certified Speech Pathologist's name or Certification Number is appropriate

Customer / Facility Name

Department

Email for Order Confirmation

/ Carrying Lead

Accounts Payable Email

Billing

First Name

Last Name

Address Line 1

Address Line 2

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Products

ESP Kit (Product 50706LT- Adult)

Includes Powered Muscle Stimulator, 2 lead wires, Lead Wire Tester, 2 AA Batteries, 10 packages of Large E Series electrodes, Shoulder Strap Carrying bag and 1 Restorative Posture Device, 1 set of replacement pads, 2 Boxes of TENS Skin Prep wipes and 1 roll of non-adhesive wrap.

ESP Kit (Product 50706ST- Youth)

Includes Powered Muscle Stimulator, 2 lead wires, Lead Wire Tester, 2 AA Batteries, 10 packages of Small/Youth E Series electrodes, Shoulder Strap Carrying bag and 1 Restorative Posture Device, 1 set of replacement pads, 2 Boxes of TENS Skin Prep wipes and 1 roll of non-adhesive wrap.

Ampcare ES Unit (Product 50710LT)

Ampcare ES Unit (Product 50710ST)

Hand-held, portable NMES unit, user manual, 10 packages of Small (Youth) E Series electrodes, 2 AA Batteries, 1 set of Lead Wires, Lead Wire tester, shoulder strap carrying bag.

E Series Electrodes (Product 50709LT- Adult)

(4 Small electrodes per package; 10 packages per pouch)

E Series Electrodes (Product 50709ST- Youth)

(4 Small electrodes per package; 10 packages per pouch)

Lead Wire Tester (Product 50713)

Ampcare Shoulder Strap Carrying Bag (Product 50714)

Replacement Lead Wire Set with Lead Wire Tester (Product 50712)

2 pair per set, Includes the Lead Wire Tester

TENS Clean-cote skin preps (Product 50711)

50 / box

Special Delivery Instructions

By checking this box, you are agreeing to receive an invoice for the products ordered in this form