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, 2 AA Batteries, 10 packages of Large E Series electrodes, Carrying bag and 1 Restorative Posture DeviceQuantity: 0Quantity: 1 KitQuantity: 2 KitsQuantity: 3 KitsQuantity: 4 KitsQuantity: 5 KitsESP Kit (Product 50706ST- Youth) Includes Powered Muscle Stimulator, 2 lead wires, 2 AA Batteries, 10 packages of Small E Series electrodes, Carrying bag and 1 Restorative Posture DeviceQuantity: 0Quantity: 1 KitQuantity: 2 KitsQuantity: 3 KitsQuantity: 4 KitsQuantity: 5 KitsAmpcare ES Unit (Product 50710LT) Hand-held, portable NMES unit, includes 10 packages of Large (Adult) E Series electrodes.Quantity: 0Quantity: 1 UnitQuantity: 2 UnitsQuantity: 3 UnitsQuantity: 4 UnitsQuantity: 5 UnitsAmpcare ES Unit (Product 50710ST) Hand-held, portable NMES unit, includes 10 packages of Small (Youth) E Series electrodes.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 packagesQuantity: 30 packagesQuantity: 50 packagesQuantity: 100 packagesE 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 packagesQuantity: 30 packagesQuantity: 50 packagesQuantity: 100 packagesE 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'sQuantity: 10 RPD'sRestorative Posture Device Replacement Pads (Product 50708) Quantity: 0Quantity: 1 setQuantity: 2 setsQuantity: 3 setsQuantity: 4 setsQuantity: 5 setsTENS Clean-cote skin preps (Product 50711) 50/boxQuantity: 0Quantity: 1 BoxQuantity: 2 BoxesQuantity: 3 BoxesQuantity: 4 BoxesQuantity: 5 BoxesAmpcare ES Replacement Lead Wire Set (Product 50712) 2/setQuantity: 0Quantity: 1 setQuantity: 2 setsQuantity: 3 setsQuantity: 4 setsQuantity: 5 setsBy checking this box, you are attesting to your e-signature *Signature ConfirmationAdditional Comments or Suggestions VerificationPlease enter any two digits *Example: 12This box is for spam protection - please leave it blank: What people say about us "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!" , “Clear presentation – good labs – hands on assistance – instructor’s style conducive to learning.” , “Great presentation! Ampcare has provided a much needed alternative to dysphagia treatment.” , “Excellent class – went over all things in very explicit detail. Will make me a better therapist at what care I’m providing.” , “Presenters were very knowledgeable and passionate. Presented information in a way that made learning fun! “ , “I thought it was the best E-Stim course I have ever taken, with excellent rationale for their protocol.” , "Excellent course! Loved the application & knowledge gained to exercise physiology! Really makes everything come together!" , “This CEU course was excellent and the instructors were superb! I would highly recommend it as the best dysphagia course I have taken to date!” , “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.” , "The Ampcare Team made learning fun, and has been accessible for any questions! Great new tool!" , 2018 Overall Rating: 4.94 out of 5 stars
