HEALING LASERS

Request to Participate in Stop Smoking Using Low Level Laser Therapy study.

Date:

Name:

Phone #:                                                           Fax#

Email Address:

Site Location (or Proposed Site Location)

Address:

City:                                                     State:                                                    Zip:

Type of Facility:

Do you have any experience providing healthcare (previous or current)?

If yes, please describe.

 

If not, do you have the ability to coordinate with a Licensed HealthCare Provider as a Medical Director for your site?  Please explain.

 

Understand there is an estimated initial cost to you of $ 6,000 or so to obtain the study laser equipment $2,250, IRB monitoring for the first year $ 1,000 and initial training. 

Payment will be required as services are rendered.

IRB submission and training must be in place before beginning study participation

PLEASE COMPLETE AND FAX BOTH PAGES TO :   480-393-4489  

You will receive a reply within two business days.  

Study Portable Unit (complies with quality study guidelines*)
Portable laser controller including 1 -650nm/50mw laser head, 1- 808nm 150mw laser head, 2 - 635nm/5 mw laser heads, foam lined heavy duty weather proof plastic carry case, 2 sets of protective goggles. 1 - wand extension cord (compliance with quality study required*)                        $ 2250 + IRB (below)

Study Desk Top Laser Unit (complies with quality study guidelines*)
Digital desk top controller with timer, 650nm/5mw spot laser wand, a 808nm/150mw spot laser wand, foam lined plastic carry case and 2 sets of protective goggles with switches on BOTH WANDS
(compliance with quality study required*)                                  $ 2250 + IRB (below)

IRB registration and first years monitoring* 
(compliance with quality study required*)                                   $1000     

Shipping: (FREE to USA - $ 85 to Canada)


Total fee to be charged to credit card for either one portable or one desk top study laser, IRB registration and first years monitoring will be                     $ 3,250

Name on card_____________________________________________________________________

Billing address:__________________________ City: _________________ State: ____ Zip: ______

Phone number _____-_____-________ Fax Phone number _____-_____-________

E-Mail Address ________________________________

Card Number _____________________________________________

Card Type: __________ Exp date:__________ Security code (3 or 4 digit) _____________

All components are guaranteed against defects for one year (dropping is excluded). Components are custom made to order and are NOT returnable. We supply and custom made cold laser components for scientific and medical research use (pain reduction and other conditions) to medical professionals and clinicians only. Our cold laser equipment components and parts, are for informational and scientific research purposes only. We do not represent products we sell will achieve specific results. I agree to pay the total amount according to card issuer agreement I acknowledge my credit card statement will contain the above charges from: ACCURATE INSPECTIONS, INC, WEST PATERSON, NJ.

X_____________________________________________________ Date: _____________