$300 COVID-19 RELIEF DISCOUNT ENDS IN:

Do You Qualify to Use the Device? DEV

Personal information provided on this form is not saved by Fisher Wallace or shared with third parties. You will receive a confirmation email if you qualify.

* required fields
Do you have any implanted electronic medical devices, such as a pacemaker or deep brain stimulator? *

Do you have, or suspect you have, heart disease? *


Are you 21 years of age or older? *


Email Address *


Please keep an eye out for your confirmation email.


Check the box above before clicking "Submit"