Retailer Rentals

Please Note: This form is to be used by an operator who can physically issue you with a Pelvipro.
We can not deliver a Pelvipro via this form.

Name *

Home Address *

Post Code *

Telephone *

Email Address *

Date of Birth

Rental Admin Charge (£)

This amount is taken now from your card.

To purchase we discount your rental charge from full price of £69.99

Purchase Price after Rental (£)

Automatically taken 45 days after your product issue date, only if you wish to purchase.

Product Issue Date

Stopping the payment is easy:

Please email STOP and your name in the comments box at the bottom of the website or email to info@pelvipro.com Return the Pelvipro using the free postage label provided, please allow 7 days for delivery Clear instructions and the free postage label are found in the Pelvipro box, making returns really easy

Where/who are you renting the device from?

Card Name *

Card Number *

CVV *

Expiration(MM/YYYY) *

By ticking this box you are agreeing to pay a further £50 if the Pelvipro device is not delivered back to us with 45 days of the product issue date, we assume that you wish to purchase the Pelvipro device. You have read and agree with the Terms and Conditions

Where did you hear about Pelvipro? (You can tick more than one box if appropriate.)

Youtube
Facebook
Friend recommendation
Therapists recommendation
Other