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© 2002
General Medical Co.
Order Online

Order online using your credit card (Visa/MasterCard only) via our secure online order form.
Mail or Fax

(Please Print)        FAX (310) 826-5778

Name

AddressApt. 

City, State, Zip

Country

Note: Your country may add customs duties and taxes as well as other charges.

Additional charges imposed by British Government and EU Countries:
Customs duties and taxes plus administrative fee for customs clearance.

Telephone

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Please send the following:

Underarms at $139.95ea. pair

Hands/Feet at $139.95ea. pair

Special Applications at $195 ea.

Add $10 for shipping/handling to the cost for each Drionic.

CA residents add 7 1/4% sales tax. Los Angeles residents add 8 1/4% sales tax.

MC/Visa#Exp. date: 

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(cardholder)

Send Check/M.O. and this form to:

General Medical Co.     Dept. WWW-4
1935 Armacost Ave.
Los Angeles, CA 90025-5296
Phone

MasterCard or Visa only
1-800-HEAL DOC or 1-800-432-5362
(310) 820-5881 (outside U.S.A.)
 

HEALTH PLAN REIMBURSEMENT

The Drionic device is reimbursable by many health plans. If you wish to submit a claim to your health plan for reimbursement you will need a prescription from your doctor, primarily a dermatologist. There are two ways to obtain Drionic under a health plan:

1. Send payment with order for immediate purchase and file claim for later reimbursement from your health plan.

2. Obtain preauthorization from your health plan for purchase of Drionic. When you receive authorization from your health plan indicating that they will cover purchase, then send us your complete payment. You then know that you will be reimbursed by your plan.


Codes needed by insurance company:
CPT = E1399
ICD-9 = 780.8

PURCHASES OUTSIDE USA

Canada - add $12.00 to each $139.95 Drionic purchased.
Other Countries - add $44.50 to each $139.95 Drionic purchased.
ALL PAYMENTS ARE TO BE MADE IN U.S. DOLLARS ON US BANK
Note: Your country my charge customs and taxes.