Practitioner Request Form

Request a Sample for a Colleague

You are requesting a sample for a Colleague. Click here if you want to request a sample for yourself.

To receive a free sample your colleague must be a degree qualified practitioner who deals with musculoskeletal problems. Limited to one per clinic.

NOTE: This form autosaves the form data that you enter as you progress to ensure you don't accidentally lose your data if the page reloads accidentally etc. IF YOU ARE ON A PUBLIC DEVICE and there is potential that you may not complete the form, you can click the button below and we will not autosave your form data. All form data is cleared after the form is submitted successfully.

Sample for colleague request form

Sample Request Successful

Thank you for your request for a sample massager for a colleague. We have sent you an email confirmation of your submission details. Please contact us if you do not receive this email.

Submission Details

Name:

Email:

Submission Date:

If you entered an email address, your submission details have been sent to you in an email.

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Your Details

Colleague Details

(eg.Chiropractor, Physiotherapist, Osteopath)

Colleague Postal Details

(I need this to know where to send the package)


Additional Details

This form collects your details (name, email, address etc) so that we know where to send the package. Check out our privacy policy for the full story on how we protect and manage your submitted data. We will never sell your data and we will never share it unless absolutely necessary to complete an action required by you, for example, with a courier to send an order to you or similar.

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