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Biofeedback Supplies Order Form 10.05

· · · · Purchase orders are accepted subject to credit review. Payment must accompany all other orders. VISA, MasterCard and American Express accepted. All prices are F.O.B. Redmond, WA. All prices are payable in U.S. dollars. Sales tax charged in WA, MA, NJ, MN only.

To place an order, please call 800-345-5642 or Fax 800-886-2774

(New Customers: Your Customer Number will be assigned when you place your first order.)

Bill To

Name: Address:

Customer No: Name: Address:

Ship To

Fax order confirmation: Yes No

Ordered by: Phone: Date: Fax:

Ship to Attn: Ship by Ground Freight unless otherwise circled: PO No: Overnight Second Day

Part No.

4509C 4510C 4520 4525 4632 6000A 6000Z 4630 4636 4639 4651 4654 4672 4674 84411271 910300-015 910300-016 4603 4632 4924 4926 4926P 4923S 4924A 4920 Call 800-345-5642

Sensors for Biofeedback & E-Stim (Single User)

SRS SenseRxTM Vaginal Sensor (EMG Biofeedback and E-Stim) - Each SRS SenseRxTM Anal Sensor (EMG Biofeedback and E-Stim) - Each MEPTM Disposable Anal Sensor (Multi-Site EMG Biofeedback) - Each IVS-2 Sensor (Eisman-Tries Intravaginal Biofeedback) - Each UroGlide--Hygienic lubrication to assist with sensor insertion (100 to Bag)



E-Stim (Electrical Stimulation)

4-ContiTM Stimulation Unit - Each 4-Conti Rental Unit (By prescription) ­ Call for forms - Each

Electrodes & Cables

Pre-Gelled Electrodes (50 sets of 3) EMG Smart Sensor Electrodes (100 ea. Triodes) Pre-Gelled Electrodes w/wires attached (100 sets of 3) EMG Lead Set (3 per set for Cable No. 4654) EMG Safety Cable - Each Temperature Sensor (Thermistor) - Each Respiration Belt - Each

Patient Devices and Supplies

StepFreeTM Vaginal Cone Set C3® Penile Clamps Size Regular (6/box) C3® Penile Clamps Size Large (6/box) Personal Care Kit for Bladder Health UroGlide--hygienic lubrication (100 to Bag) "Beyond Kegels" by Janet A. Hulme, MA, PT - Each "Fibromyalgia, A Handbook for Self Care & Treatment," Phoenix Publishing "Bladder & Bowel Issues for Kids" by Janet A. Hulme, MA, PT - Each

Professional Educational Materials and Courses

"Biofeedback, A Practitioner's Guide" 3rd Edition, Mark S. Schwartz - Each "Beyond Kegels Book II, A Clinician's Guide to Treatment, Algorithms & Special Populations" by Janet A. Hulme, MA, PT - Each Brochure: "Ten Most Commonly Asked Questions" (100 per Pack) 2-Day Biofeedback Courses and 1-Day Specialty Courses- Quarterly

C3 is a registered trademark and SenseRx, MEP and StepFree are trademarks of SRS Medical Corp. All other trademarks are the property of their respective manufacturers.

14950 NE 95th St., Bldg. F, Redmond WA 98052 USA

800-345-5642 or +1-425-882-1101

Fax 800-886-2774


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Microsoft Word - Biofeedback Supplies 10.05.doc