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Please check this box if you have specific clinical guidelines or device design preferences and would like to speak with a technician.

I acknowledge that True Function will contact me to obtain payment details. Payment must be received prior to the first shipment.

By submitting this form, I confirm that the information provided is true, accurate, and complete. I authorize True Function Laboratory, Inc. to charge the card on file at the end of each month for my statement balance and/or any unpaid services from previous months.

If a payment is declined, the office will be notified, and we kindly ask that payment be made promptly. If payment is not received by the end of the following month, a 2% finance charge may be applied to the outstanding balance.

I understand that I am responsible for all charges incurred with True Function Laboratory, Inc. and agree to notify the office of any changes to the information provided. By submitting this form, I acknowledge and agree to the terms outlined above.

*If you prefer an alternative payment method, please let our team know when you are contacted to collect payment information.

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