Activity Monitoring Enrollment

Dear Sir/Madam:

thank you for your interest in the activity monitor (See article at the bottom of this page).

To help set-up the evaluation, please copy the following form and E-mail it to [email protected] with all the required information:

In the body of the e-mail included:

Subject’s First and Last Name
Gender
Date of Birth
Diagnosis
Medication name and dose
First and Last Name of the person the monitor will be sent to
Address where the monitor will be mailed to (no PO Box, please)
Telephone number of the person the monitor will be sent to
Master/Visa Credit Card # and Expiration date
(or call Cindy at 1-800-695-9005 ext. 2971)
_________________________________________________________

You will be billed by Credit Card $150.00, that includes the rental of the unit and data analysis by Circesoft).
The final report will be billed separately by our office.
__________________________________________________________
When you have received the unit, please read the instructions carefully.
I will contact you as soon as the results are available, and discuss it with you.

Regards,
Gianni Faedda