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Do You Qualify to Use the Device?

The personal information provided on this form is not saved by Fisher Wallace or shared with third parties.

* 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 pregnant? *


Are you 21 years of age or older? *


Are you experiencing any symptoms of depression or anxiety, or do you have trouble falling asleep or staying asleep? *