(214) 377-8144 sales@dermitech.com

Authorized Representative

Aquex Product Order Form

 

Shipping Address (if different from above)

Product Choices (check all that apply)

Confirmation

I confirm that the above information is accurate and complete to the best of my knowledge. I agree to follow my prescriber’s instructions for the proper use of this medical device.
It is important to understand the size, weight and electrical requirements of your device. Please discuss these details and any special delivery needs you may have with your Dermitech representative by calling 214-377-8144.

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