MyoTrac -Highly Sensitive Compact EMG Monitor

Thanks you for ordering Procomp+ Online. Please fill out the form and submit it, or print it, send my mail or fax it to the address below. 

Your Name:
Company:
Billing Address:
Address1:
Address2:
City:
State: ZIP:
Country:
Phone:
Fax:
E-Mail:
URL:
Procomp+ $3,900.00 (including Biograph Software)
(Procomp+ 60 Hz PIN Protected System)
Add active sensors to the system:
HR/BVP Sensor:
Skin Conductance Sensor:
Temperature Sensor
Respiration Sensor:
MyoScan Pro V2 EMG Sensor:
EEG Sensor V2: (mono-polar)
EEG Sensor V2: (bipolar)
EKG Sensor:
10/20 Conductive EEG Paste: $20.00 (optional, included when you order an EEG sensor)
Voltage Isolator System: $400.00 (optional)
Fiber-Optic Cable: (optional)
Sensor Extender Cables
[x3, 7.25 in(18.5 cm)]		 $20.00 each (optional, free extender cables are supplied with EEG, EKG and EMG sensors).
How many:
Shipping:
Payment Method:
If Credit Card option selected, please enter the following:
Credit Card Number:
Expiration Date:
Cardholder:
 

_______________________
(cardholder's signature if sent by fax/mail)
TOTAL ORDER: (please calculate total)
Shipping Address (if different) and comments


You should receive a confirmation within 24 hours by e-mail or phone.

US Orders by check: Please fill out, print and send this form along with your check to the address below.
International Orders: Please contact us for bank wire transfer information.

Web Ideas International, Inc.
#110, 4335 Pheasant Ridge Drive NE
Suite 224, Blaine MN 55449
U.S.A.

If you have any questions or problems, please e-mail or call 651.494.3977 ext.1. Thank you!