RELIVION® MG SYSTEM

The Relivion® MG system consists of (1) a headset, power cord, and disposable pads needed for use (“Device”), and (2) the Relivion® MG app (“App’). The Device is a medical device regulated by the Food and Drug Administration (“FDA”) and requires a prescription from an authorized prescriber in order to be dispensed by Advanced Medical DME to Patient. Patient agrees that s/he will not sell or transfer the Device to any other person.

60-DAY EVALUATION PERIOD

A $150 non-refundable payment is required to ship the Device and initiate the 60-day evaluation period. It is your responsibility to schedule a virtual training session with a Relivion MG training coach for instructions on use of the Device and App, or select the self-training option, if available. The 60-day evaluation period begins on the earlier of the day of your training session, the day you first use the device or 30 days after the date that the Device was shipped to you.   You can find the Device user’s manual with full instructions for use of the Device at www.relivion.com.  Should you have questions regarding any possible warnings and contraindications, please contact Advanced Medical DME.  Advanced Medical DME will send you the Device and a supply of disposable pads for normal use, based on your prescription, with free ground shipping during the 60-day evaluation period.

RESULTS NOT GUARANTEED

Results from use of the Device are not guaranteed. No warranty or guarantee has been made as to the results of this therapy.

OPTIONS AFTER 60-EVALUATION TRIAL PERIOD

At the conclusion of the 60-day evaluation period, you will automatically be charged a One Payment Purchase as described below, commencing on the first day after expiration of the 60-day evaluation period unless you enact another option, before the expiration of the evaluation period.  

Option 1 Return the Device

If you elect to return the Device, you must (1) notify Advanced Medical DME in writing at support@relivion-medical.com before the end of the 60-day evaluation period, and (2) return the Device (including headset, power cord, and all unused disposable pads) to Advanced Medical DME no later than 15 days after expiration of the evaluation. Upon receipt of your return notification, Advanced Medical will provide you with a pre-paid return label. You must use the provided pre-paid return label to return the device to Advanced Medical DME. You will be charged for the One Payment Purchase if the Device(s) are received by Advance Medical DME more than 15 days after the expiration of the evaluation period, or without written notice of the return prior to the expiration of the evaluation period. 

Option 2 One Payment Purchase

The suggested list price of the Relivion MG system is $2,000. The total cash price offered under this agreement is $800. By selecting this option, we will apply your $150 evaluation fee toward the purchase price, and you will be charged one payment of $650 one day after the expiration of the evaluation period. We will ship 1 additional box of pads complimentary at the time of your purchase. You will be responsible for purchasing additional disposable pads and replacement accessories as needed after the 60-day evaluation period. 

Option 3 Monthly Installment Purchase

The suggested list price of the Relivion MG system is $2,000. The total cash price offered under this agreement is $800. By selecting this option, we will apply your $150 evaluation fee toward the purchase price (for a discounted purchase price of $650), and you will pay 3 monthly payments of $216.67, commencing 1 day after the evaluation period ends. You will be responsible for purchasing additional disposable pads and replacement accessories as needed after the 60-day evaluation period. 

ADDITIONAL CHARGES AND METHODS OF PAYMENT

Expedited shipping charges that are requested by the Patient and all applicable taxes, duties, customs and fees will be added and shall be payable by Patient.  Advanced Medical DME accepts credit cards, money orders and certified bank checks only.  

LATE PAYMENTS

Any payment not made when due shall accrue interest up the rate of 1.5% per month (18% per annum), or the highest rate allowed by law if lower, until paid in full.  In the event you fail to make a payment when due, you agree to pay all reasonable costs of collection incurred by Advanced Medical DME, including attorneys’ fees.  If you are delinquent in your payment, Advanced Medical DME may suspend shipment of any additional disposable pads until all past due amounts have been received.

PATIENT CONSENT AND ACKNOWLEDGEMENT

I accept full and complete responsibility for all charges for the Device. I acknowledge that Advanced Medical DME’s training coaches that are working with me (or anyone acting on their behalf) will have access to my individual data captured by the Device or App as part of my interaction with Advanced Medical DME’s training coaches for the purpose of providing me with services, training and support as a patient using the Device for so long as I am using the Device. I have read and fully understood the Privacy Policy available to me in the App and on www.relivion.com. I authorize Advanced Medical DME to rely on my recorded electronic signature on this document as true, correct, and binding.  

RESOLVING COMPLAINTS

You have the right to freely voice grievances and recommend changes in care or services without fear of reprisal or unreasonable interruption of services. Service, equipment, and billing complaints will be communicated to management and upper management. These complaints will be documented in the Complaint Log, and completed forms will include your name, address, telephone number, a summary of the complaint, the date it was received, the name of the person receiving the complaint, and a summary of actions taken to resolve the complaint. All complaints will be handled in a professional manner. All logged complaints will be investigated, acted upon, and responded to in writing or by telephone by a manager within a reasonable amount of time after the receipt of the complaint.

DEVICE WARRANTY INFORMATION

The Relivion MG Device comes with a 1-year limited manufacturer’s warranty. Advanced Medical DME will replace or repair any Relivion device that is under this 1-year warranty free of charge for any manufacturing defects in workmanship and materials. Modifications made to the Device may void the warranty and the repair and replacement option. Advanced Medical DME shall not be responsible for any personal injury or property damage related to any product, including that caused by improper use or function thereof, the act or omission of any third party, or by any criminal act or activity, fire, or act of God.

(OPTIONAL) EXTENDED WARRANTY INFORMATION

You may opt to purchase a 1-year extended manufacturer’s warranty for your Relivion device for $50 at the time of your initial purchase. Advanced Medical DME will replace or repair any Relivion device that is under this extended 1-year warranty free of charge for any manufacturing defects in workmanship and materials.

PATIENT RIGHTS AND RESPONSIBILITIES

Advanced Medical DME will provide patients, caregivers, customers, facilities and health care providers with general information concerning our staff and time frame for completing physician orders and delivery times.

Patient Rights:

• You have the right to considerate and respectful service.
• You have the right to obtain service without regard to race, creed, national origin, sex, age, disability, diagnosis or religious affiliation.
• Subject to applicable law and our privacy policies, you have the right to confidentiality of all information pertaining to your medical equipment service.
• You have the right to make informed decisions about your care.
• You have the right to reasonable continuity of care and service.
• You have the right to voice grievances without fear of termination of service or other reprisal in the service process.

Patient Responsibilities:     

• You are responsible to promptly notify us of any equipment failure or damage.
• You are responsible for any equipment that is lost or stolen while in your possession and should promptly notify us in such instances.
• You are responsible to promptly notify us of any changes to your address or telephone.
• You are responsible to promptly notify us of any changes concerning your physician.