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How It Works
Free Exercise Prescription
Buy or Rent a Pelvipro
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.
Home Address *
Post Code *
Check Box Only if Billing Address is Different
Billing Address *
Billing City/Town *
Billing County *
Billing Post Code *
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 email@example.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 *
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.)
Find out more.
Okay, thank you