FREE IN-HOME TRIAL

We are so convinced we can help you ...
we provide a no-risk, no-cost, no-nonsense FREE in home trial to prove we can deliver real results.

HOW THE FREE IN-HOME TRIAL WORKS:

1) We will send you Web Cam and Our proprietary Class 2 medical device.

2) We will evaluate your specific condition and needs in the comfort of your own home.

3) We will do 1 treatment FREE to demonstrate we can deliver real results that will work for you.

GUARANTEE: If after your first treatment you do not believe we can help you send the Web Cam and the device back, at our cost (a value of $100.00) and you pay nothing.

 Avoid ACL Surgery

Top athletes and many regular people worldwide have avoided painful ACL surgery with our system. Our proprietary acl knee treatment system really works and in most cases allows our patients to avoid acl surgery altogether. Our treatment can often repair acl, repair torn acl, resolve acl injuries, help patients experience faster recovery from an acl tear and avoid reconstruction surgery. Torn ACL and tears in your ACL can be treated in many cases with going under the knife and risking dangerous surgery. Rehabilitation of your acl is possible is less time, at a lower cost and easier than you ever imagined.

 Avoid Hip & Knee Replacement Surgery 

You probably don't need that expensive and risky hip replacement or knee replacement surgery, we have a sensible and cost effective alternative to knee and hip replacement surgery which has been used by many of the world's top athletes. Our treatment can help you avoid hip replacement surgery or knee replacement surgery, stop the need for a knee brace or hip brace, help speed recovery of knee cartilage or total hip replacement recovery. We provide hip replacement alternatives and knee replacement alternatives not found elsewhere. You can recover from knee injury or hip injury faster than you ever thought possible with our unique system.

 Avoid Carpal Tunnel, Back Pain, or TMJ Surgery

Before you consider going under the knife and having risky surgery for carpal tunnel syndrome, back pain, herniated disc or TMJ you should consider a safer, less expensive option for these conditions which has provided long term relief for 90% of our patients. Whether you are suffering from carpal tunnel, back pain or TMJ, we have a solution for you. Don't risk unecessary surgery, long recovery times, risks of complications and the expense of insurance deductibles when there is a safer, faster and far less risky alternative that really works.

ALL FIELDS MUST BE COMPLETED OR THIS FORM IS INVALID
ALL INFORMATION IS KEPT STRICTLY CONFIDENTIAL V3.2

SECTION #1

Preset Field - Do Not Change: SALES NETWORK IN HOME TRIAL FORM
Preset Field - Do Not Change: Pro5.com/Painfree/index.html

Name:  Date Of Birth: Today's Date:

Home Address :  City :   State :  Zip :

Home Phone : Work Phone : Cell Phone : Drivers License # :

Best Time To Call To Setup An Appointment With You: Best Number To Call: PLEASE SELECT... Home # Work # Cell #

Sex: PLEASE SELECT... Male Female    Marital Status: PLEASE SELECT... Married Single Divorced Widowed Employment Status: PLEASE SELECT... Full Time Part Time Unemployed Retired    

Email: Who Referred You/How Did You Hear About Us:

Do You Need A Webcam: PLEASE SELECT... Yes, I need a Webcam No, I do not need a Webcam Do You Want Financing: PLEASE SELECT... No Yes

What Is The Term Of The Lease You Want ( how many days ): PLEASE SELECT... 5 days 10 days 30 days 60 days

HOME TRIAL AGREEMENT - YOU MUST READ THIS BEFORE PROCEEDING!
INDIVIDUAL PRESCRIPTION DEVICE LEASE LESSOR: ARP Wave, LLC 7721 145 Street West Apple Valley, MN 55124 (952) 431-9708 LESSEE: Name _______________________________________________________ Address _____________________________________________________ City____________________________________________ State________ Zip_______________Email _____________________________________ Home Phone ______________________Cell________________________ FREE IN-HOME TRIAL: We are so convinced we can help you we provide a no-risk, no-cost, no-nonsense FREE in home trial to prove we can deliver real results. HOW THE FREE IN-HOME TRIAL WORKS: 1) We will send you Web Cam and Our proprietary Class 2 medical device called the ARP. 2) We will evaluate your specific condition and needs in the comfort of your own home. 3) We will do 1 treatment FREE to demonstrate we can deliver real results. GUARANTEE: If after your first treatment you do not believe we can help you send the Web Cam and the ARP back, at our cost (a value of $100.00) and you pay nothing. PRESCRIPTION DEVICE EQUIPMENT LEASE ARP Wave, LLC (hereinafter referred to as "Lessor"), hereby leases to (hereinafter called "Lessee") the equipment, described on Page 1, upon the following terms and conditions. 1. Rent and Term. After agreement to proceed with treatment the Lessee authorizes Lessor to debit his/her credit card for $2600.00, to begin treatment and keep the ARP Device for the duration of the specified lease period. If Lessee does not wish to keep the ARP Device after the FREE evaluation and treatment he/she agrees to repackage the device and ship unit back to Lessor within 24 hours. There is no cost to the lessee. If for ANY reason licensee decides NOT to have the FREE evaluation after Licensor has shipped to them licensee agrees to pay for return shipping costs. Licensee agrees to complete the FREE evaluation within two days of the arrival of the unit or agrees to pay for the treatment program. Lessee's obligations to pay all rent and all the rights of Lessor in and to such payments, shall be absolute and unconditional and shall not be subject to any abatement, reduction, set-off, defense, counter claim or recoupment for any reason. 2. Surrender. Upon the completion of the initial 10 treatments unless you decide to rent , the following day you must return the ARP, ALL accessories on the inventory list including the travel case, and the web cam. If we do not receive all items back we will debit your credit card for items missing until they are returned. Upon return of said items we will immediately CREDIT your credit card. Upon completion of treatment 10 should you decide to rent, your therapist will go over the rental agreement with you and your rental time will begin the next day. Should you decide to License, your therapist will go over the paperwork with you. Upon execution of the paperwork we will send your new ARP to you. Should you decide not to return our ARP, you agree you are fully responsible for the full license cost. 3. FDA Compliance: The standard indications approved by the FDA for use for the ARP Device under 21 CFR 890.5850 are: Relaxation of muscle spasms; Prevention or retardation of disuse atrophy; Increasing local blood circulation; Muscle re-education; Immediate post-surgical stimulation of calf muscles to prevent venous thrombosis; and Maintaining or increasing range of motion. Federal law restricts the ARP device to sale or lease by or on the order of a practitioner licensed by the law of the State in which he/she practices to use or order the use of the device. Lessee, by signing below, acknowledges that he/she has obtained a prescription for the use of the ARP Device from a licensed practitioner sanctioned by Lessor. Lessee agrees not to use the ARP Device on, or allow its use by, any third parties. 4.Ownership and Alterations of Equipment. The ARP device shall at all times be and remain, the sole and exclusive property of the Lessor and the Lessee shall have no right, title or interest therein or thereto except as expressly set forth in this Lease. 5.Default. If Lessee shall be in default under any terms or conditions of this Agreement or any other agreement executed with Lessor, Lessor shall have the right to exercise any one or more of the following remedies: a.To sue for and recover all rents, and other payments, then accrued or thereafter accruing, with respect to all items of equipment; b.To take possession of any or all items of equipment without demand or notice, wherever the same shall be located, without any court order or other process of law. The Lessee hereby waives any and all damage occasioned by such taking of possession; c.To terminate this Lease as to any or all items of equipment; d.To pursue any other remedy at law or in equity. Notwithstanding any said repossession or any other action which the Lessor may take, the Lessee shall be and remain liable for performance of all obligations on its part to be performed under this Lease. Lessee hereby waives any and all damages occasioned by the exercise by Lessor of any of Lessor's rights or remedies upon the occurrence of an event of default under this section. Lessee agrees to indemnify Lessor for all costs and expenses, including reasonable attorneys' fees, incurred by the Lessor in connection with the enforcement by it of any of its rights or remedies under this Equipment Lease Agreement. 6. Construction, Consent to Jurisdiction and Service of Process. EACH PARTY CONSENTS TO THE JURISDICTION OF ANY STATE OR FEDERAL COURT LOCATED WITHIN THE COUNTY OF HENNEPIN, STATE OF MINNESOTA AND IRREVOCABLY AGREES THAT ALL ACTIONS OR PROCEEDINGS RELATING TO THIS AGREEMENT OR ANY RELATED AGREEMENTS MUST BE LITIGATED IN SUCH COURTS. EACH PARTY ACCEPTS FOR ITSELF, GENERALLY AND UNCONDITIONALLY, THE EXCLUSIVE JURISDICTION OF THE AFORESAID COURTS AND WAIVES ANY DEFENSE OF FORUM NON CONVENIENS. EACH PARTY FURTHER IRREVOCABLY CONSENTS TO THE SERVICE OF PROCESS OUT OF ANY OF THE AFOREMENTIONED COURTS IN ANY SUCH ACTION OR PROCEEDING BY THE MAILING OF COPIES THEREOF BY REGISTERED OR CERTIFIED MAIL, POSTAGE PREPAID, TO THE PARTY AT THE ADDRESS SPECIFIED IN THIS AGREEMENT. NOTHING HEREIN SHALL IN ANY WAY BE DEEMED TO LIMIT THE ABILITY OF ANY PARTY HERETO TO SERVE ANY SUCH LEGAL PROCESS, SUMMONS, NOTICES AND DOCUMENTS IN ANY OTHER MANNER PERMITTED BY APPLICABLE LAW. 7. Waiver of Jury Trial. EACH OF THE PARTIES HERETO HEREBY WAIVE THEIR RESPECTIVE RIGHTS TO A JURY TRIAL OF ANY CLAIM OR CAUSE OF ACTION BASED UPON OR ARISING OUT OF THIS AGREEMENT. Patient: _______________________________________ * Lease Start Date: ____ * Payment Amount: $2600 * Duration of Lease: 5 days * Type of Card: ___MC ___VISA ___AMERICAN EXPRESS * Card #_______________________________ * Expiration Date________________________ * Security Code_________________________ * Driver’s License # ______________________ * Address Card billed to __________________________________ * Driver’s License #______________________________________

I have read and agree to the above: PLEASE SELECT... Yes, I agree No, I do not agree
If you do NOT agree to ALL of the terms and conditions of this agreement above please press the HOME button below:   

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SECTION #2

Preset Field - Do Not Change: CONTRAINDICATIONS FOR ARP --------------------

Please check all present symptoms related to your current condition:
Are you pregnant: PLEASE SELECT... Yes, pregnant No, not pregnant     
Any pacemaker or ICD: PLEASE SELECT... Yes, I have a Pacemaker or ICD No Pacemaker or ICD
Any history of bloodclots: PLEASE SELECT... Yes, Blood Clot history No Blood Clot history
Primary care physician name:   Phone:

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Preset Field - Do Not Change: PRESENT CONDITION --------------------
To help meet your needs, please indicate your specific interests: PLEASE SELECT... Eliminate Pain Prevent surgery ARP Treatment Muscle injury Muscle rehabilitation pre or post surgery Muscle strengthening for spinal cord injuries Muscle strengthening for neurological diseases Chiropractic care Neurological evaluation Nutrition/Dietary counseling
When did your complaint/symptoms begin:
Describe your complaint/symptoms:
Where is the location of your pain:
Rate intensity of your pain: PLEASE SELECT... 0-1 No Pain 2-3 Mild Pain 4-5 Moderate Pain 6-7 Severe Pain 8-9 Very Severe Pain 10 Worst Possible Pain
What does your pain feel like: PLEASE SELECT... Aching Burning Numbness Pins & Needles Stabbing
What was the cause of the symptoms: PLEASE SELECT... Auto Accident Athletic Injury Work Related Injury Post Surgery Just Came on
What activity bothers you the most:
What activity lessens your symptoms:
How have symptoms progressed:

What treatments have you done (check all that apply):
Massage    Medication    Physical Therapy    Rest / Ice / Compression
Surgery Chiropractic Alternative

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Preset Field - Do Not Change: MEDICAL HISTORY --------------------
Primary Medical Physician:   Phone:

Do you have any medical records that have been created : PLEASE SELECT... Yes No
Have you seen another doctor because of your current condition: PLEASE SELECT... Yes No   
If so, the name of the Physician:
If so, what was the result:
Do you have any allergies, if so list them:   

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Preset Field - Do Not Change: DIAGNOSTIC TESTS --------------------
Have you had any diagnostic tests performed by any Doctors (check all that apply):
MRI    X-Rays    Lab Work    Functional Testing   Psychological Testing    Electrodiagnostics    Other(s)
If so, what were the results of the test :

Are there any additional comments about your condition that you feel would be important for us to know:

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SECTION #3

In order for us to treat you after your FREE initial evaluation you must have a valid credit card or checking account as we can not take cash. Which would you like to use ... complete the information next to EITHER Payment by Credit Card or Payment by Check:

PAYMENT BY CREDIT CARD:
Credit Card Number:  Expiration:  Security Code :  

or

PAYMENT BY CHECK:
Bank Name:  Banks Address:  
9 Digit ABA Routing Number: Account Number:

 

Truthful Representation:
Upon selecting the following box stating "ALL INFORMATION IS TRUE" I hereby state that all the information I have provided is true, correct and complete. If more information about my condition becomes known, I will tell the doctor when possible so that it can be added to my record:

PLEASE SELECT... ALL INFORMATION IS TRUE

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SECTION #4

Refer a friend(s) and we will offer them a FREE treatment to prove we can help them:
Phone # :
Phone # :
Phone # :
Phone # :

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SECTION #5

Release of Liability:
In conjunction with my treatment with the ARP at ARP Wave Clinic and as part of the consideration for my treatment,
I, my heirs, executors, spouse, successors, assigns, offspring, agents, and representatives expressly release, hold harmless,
and indemnify the ARP Wave Clinic its owners, agents, employees, representatives, assignees, licensees, and invitees,
from all liability for any treatments given.

Press this buton to submit your information:
If you do NOT agree to ALL of the terms and conditions of this agreement above please press the HOME button below.

WE CAN SHOW YOU HOW TO AVOID SURGERY
AND LIVE PAIN FREE!