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Get a Free PM Rehab Massage Chair for Your Clinic

We're here to help! Expect a response within 24 hours.

Contact Form

Please fill out the information below, and our team will get in touch with you shortly.

Contact Information

• Contact Person (Full Name): ____________________________

• Business Name: ______________________________________

• City & State: _________________________________________

• Email Address: _______________________________________

• Phone Number: _______________________________________

• Preferred Delivery & Installation Date: ____________________

Interest Inquiry

Let us know your area of interest:

• ☐ I am interested in a free Rehab massage chair

• ☐ I am interested in referring business opportunities

Prospective Lead General Info

Company Details

• Company Name: ________________________

• Contact Name & Title: ________________________

• Phone & Email: ________________________

• Professional Medical License & Number: ________________________

• Issued Date & Licensing Authority: ________________________

• Number of Locations: _______

• Wi-Fi Access: ☐ Yes ☐ No

• Website: ________________________

Installation Details

• How many locations for a FREE Rehab Massage Chair? ___________
  (Recommended: 1 chair per 3 physical therapists)

• Installation Address: ________________________

• Number of Physical Therapists: ___________

• Estimated Daily Patients: ___________

• Average Therapy Time:
  ☐ Less than 20 mins
  ☐ 21-30 mins
  ☐ 30-60+ mins

Company General Information

• Legal Business Name: ________________________

• DBA (if applicable): ________________________

• Business Contact Person & Title: ________________________

• Business Address: ________________________

• City, State, ZIP: ________________________

• Phone & Fax: ________________________

• Email: ________________________

• Legal Form of Business:
  ☐ Corporation
  ☐ Partnership
  ☐ Proprietorship
  ☐ LLC

• Business Start Date: ___________

• State of Incorporation/Registration: ___________

• Number of Employees: ___________

• Number of Locations: ___________

• Avg. Daily Customer Traffic: ___________

• Owner’s Cell: ________________________

• Wi-Fi Available: ☐ Yes ☐ No

• Property Insurance Agent Name & Contact: ________________________

• Door Dimensions:
  Length: _______ Width: _______

• Business Type Description: ________________________

Corporate Officers / Partners / Owners

Name _____________________                 Title   ____________________                            Ownership % ____________________

Additional Message

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