RASHA UPGRADE CLIENT FORM

First Name

Last Name

Phone

Email

Do you have a Pacemaker? *

Yes

No

Are you currently undergoing chemotherapy or radiation treatments? *

Yes

No

Do you have a history of seizures? *

Yes

No

What are you hoping to address with your RASHA upgrades?

I declare that the information I’ve provided is accurate & complete.

I accept terms & conditions

Thanks for submitting!

198 North Ave East, Cranford, NJ 07016

(844) 612-1215 Ext 6

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