Ampcare Online Order FormDate *Purchase Order Certification or Company Number *Customer/Facility Name *Billing Contact First Name *Billing Contact Last Name *Billing Contact Email *Department Billing Address Line 1 *Billing Address Line 2 City *State / Province / Region *Postal / Zip Code *Country United StatesAfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiComorosCongo (Brazzaville)CongoCosta RicaCote d’IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast Timor (Timor Timur)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepaNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint VincentSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamYemenZambiaZimbabweShipping *Ship To Address IncludedUse Bill To Address for shippingShip To Shipping Address Line 1 Shipping Address Line 2 City State / Province / Region Postal / Zip Code Country United StatesAfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiComorosCongo (Brazzaville)CongoCosta RicaCote d’IvoireCroatiaCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast Timor (Timor Timur)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepaNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint VincentSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamYemenZambiaZimbabweShipping Contact Email *Phone *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.Quantity: 0Quantity: 1 KitQuantity: 2 KitsQuantity: 3 KitsQuantity: 4 KitsQuantity: 5 KitsESP 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.Quantity: 0Quantity: 1 KitQuantity: 2 KitsQuantity: 3 KitsQuantity: 4 KitsQuantity: 5 KitsAmpcare ES Unit (Product 50710LT) Hand-held, portable NMES unit, user manual, 10 packages of Large (Adult) E Series electrodes, 2 AA Batteries, 1 set of Lead Wires, Lead Wire tester, shoulder strap carrying bag.Quantity: 0Quantity: 1 UnitQuantity: 2 UnitsQuantity: 3 UnitsQuantity: 4 UnitsQuantity: 5 UnitsAmpcare 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.Quantity: 0Quantity: 1 UnitQuantity: 2 UnitsQuantity: 3 UnitsQuantity: 4 UnitsQuantity: 5 UnitsE Series Electrodes (Product 50709LT- Adult) (4 Large electrodes per package)Quantity: 0Quantity: 10 packages (4/pkg. 10 pkg/pouch) - 1 pouchQuantity: 20 packages (4/pkg. 10 pkg/pouch) - 2 pouchesQuantity: 30 packages (4/pkg. 10 pkg/pouch) - 3 pouchesQuantity: 50 packages (4/pkg. 10 pkg/pouch) - 5 pouchesE Series Electrodes (Bulk Quantity- Product 50709LT- Adult) (4 Large electrodes per package)Quantity: 0Quantity: 100 packagesQuantity: 200 packagesQuantity: 300 packagesQuantity: 400 packagesQuantity: 500 packagesE Series Electrodes (Product 50709ST- Youth) (4 Small electrodes per package)Quantity: 0Quantity: 10 packages (4/pkg. 10 pkg/pouch) - 1 pouchQuantity: 20 packages (4/pkg. 10 pkg/pouch) - 2 pouchesQuantity: 30 packages (4/pkg. 10 pkg/pouch) - 3 pouchesQuantity: 50 packages (4/pkg. 10 pkg/pouch) - 5 pouchesE Series Electrodes (Bulk Quantity- Product 50709ST- Youth) (4 Small electrodes per package)Quantity: 0Quantity: 100 packagesQuantity: 200 packagesQuantity: 300 packagesQuantity: 400 packagesQuantity: 500 packagesRestorative Posture Device (RPD- Product 50707) Quantity: 0Quantity: 1 RPDQuantity: 2 RPD'sQuantity: 3 RPD'sQuantity: 4 RPD'sQuantity: 5 RPD'sRestorative Posture Device (Bulk Orders) Quantify: 0Quantity: 10 ($10 off each RPD)Quantity: 20 ($25 off each RPD)Restorative Posture Device Replacement Pads (Product 50708) Quantity: 0Quantity: 1 setQuantity: 2 setsQuantity: 3 setsQuantity: 4 setsQuantity: 5 setsReplacement Lead Wire Set with Lead Wire Tester (Product 50712) 2 pair per set, Includes the Lead Wire TesterQuantity: 0Quantity: 1 setQuantity: 2 setsQuantity: 3 setsQuantity: 4 setsQuantity: 5 setsLead Wire Tester (Product 50713) Quantity 0Quantity 1Quantity 2Quantity 3Quantity 4Quantity 5TENS Clean-cote skin preps (Product 50711) 50/boxQuantity: 0Quantity: 1 BoxQuantity: 2 BoxesQuantity: 3 BoxesQuantity: 4 BoxesQuantity: 5 BoxesAmpcare Shoulder Strap Carrying Bag (Product 50714) Quantity 0Quantity 1Quantity 2Quantity 3Additional Comments or Suggestions By checking this box, you are agreeing to receive an invoice for the products ordered in this form. *For pricing, email us at info@ampcarellc.comSignature Confirmation VerificationPlease enter any two digits *Example: 12This box is for spam protection - <strong>please leave it blank</strong>: What people say about us "This course was fantastic! I learned so much and would highly recommend this to any of my colleagues. Thank you for making this presentation so digestible for the learner." -- Kevin Renz Ambrocio, M.S., CCC-SLP, - Austin, TX , , "I can honestly say this is the only course that I have ever attended where I did not want to leave the room because I would miss some great info. This course was fantastic and every slide/topic was incredibly pertinent. Never a dull moment, and the material is incredibly practical to my clinical practice. Thank you!" , “As a provider in today’s health care environment, effectiveness, quality, and value are first and foremost on our dashboard. The Ampcare protocol, device, and electrodes deliver consistent treatment allowing patients to return to their least restrictive consistency and texture.” -- Carmen Vitton, M.S., CCC-SLP, CDP, RAC-CT, - COO - Rehab Synergies , 2023 Overall Rating: 4.97 out of 5 stars