Home Exercise Package

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During this time of being home bound we wanted to give you more access to home exercise equipment. (minimum purchase of 2 or more on all bands and ice packs). Please fill out the questions below, and make your equipment purchase choices. Complete all required fields, then follow the payment instructions below, and submit this form.
We will deliver your purchase no earlier than 2 business days from your order date, on Wednesday of each week. Please do not come out to say hi as we want to maintain social distancing. We will drop your purchase off at your designated location. Thank you and stay well.

Name (First and Last) *

Phone Number (cell) to text you when delivery has been made.

Delivery address *

Special delivery instructions like beware of dog, put package by the side door, please put by the garage door, etc. *

Please choose the equipment that you would like to purchase and have delivered.

Physioball ($40), (add $5 dollars to have it blown up).

Gel Ice Pack ($5), (minimum purchase of 2 or more)

Massage Stick ($18)

Balance Disc ($18)

Shoulder pulleys ($18)

Foam Roller (Full Roll $25) 3ft long

1/2 foam roller ($20) 3ft long

Exercise bands (minimum purchase of 2 or more) ($5 each)

yellow ankle band (easy)

green ankle band (moderate)

blue ankle (difficult)

Black black (most difficult)

Yellow tube (easy)

Orange tube (moderate)

Green tube (difficult)

Blue tube (most difficult)

Other:

If a piece of equipment that you would like is not listed please let us know the name of that piece of equipment below and we will see what we can do to help you.

Agree to pay delivery fee *

By checking this box I agree to the added $8 for a delivery fee

Total your purchase up (include addition costs and delivery fee). Thank you! *

Copy and paste this link to pay https://sportspinept.securepayments.cardpointe.com/pay

or go to our website and hit the "Pay Now" button. www.nhsportandspine.com. Once you have paid then submit this form.

I would like to be contacted about Telehealth options for physical therapy *

Yes

If you answered yes above please let us know the best way to contact you for Telehealth. (type phone # or email below).

Submit

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