NRR Patient Technology Order Form Revolutionize Patient Recovery with Advanced Rehab Solutions Explore our solutions! Reach out for virtual demos and clinical webinars. ← Enter your details: Name: Email: State: Submit {{#message}}{{{message}}}{{/message}}{{^message}}Your submission failed. The server responded with {{status_text}} (code {{status_code}}). Please contact the developer of this form processor to improve this message. Learn More{{/message}}{{#message}}{{{message}}}{{/message}}{{^message}}It appears your submission was successful. Even though the server responded OK, it is possible the submission was not processed. Please contact the developer of this form processor to improve this message. Learn More{{/message}}Submitting… Form submitted successfully! Neuro Rehab Recovery Technology Order Form QUOTE #: Custom PO: Need By Date: PO #: Date: Bill To: Ship To: Attn: Attn: Address: Address: City: City: ST: ST: Tel: Tel: Zip: Zip: Billing Email: Shipping Email: Order Items Part No. Description Price Qty. Total G4G4 FES Foot Drop Kit$2,500.00 $0.00 G1XFT G1 EMG Robotic Glove$2,000.00 $0.00 Subtotal: $0.00 Sales Tax: Shipping: Total: $0.00 Date: ______________________ Quotes are only valid for 60 days. Prices are subject to change without notice. Caution: US Federal Law restricts the G4 device sales by physician prescription only. Submit Order
