OTC CUSTOM™ - Bonro Medical

Please fill out order form and submit to:
COMMON CAUSES OF ED:
THE REVOLUTIONARY NEW
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SAFE,
SIMPLE,
COMPACT,
EFFECTIVE &
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Prostate Cancer
Diabetes
High Blood Pressure
Vascular Disease
Heart Disorders
Kidney Disorders
Prescription Medications
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Mailing Address:
High Cholesterol
Spinal Cord Injury
Multiple Sclerosis
Trauma
Cigarette Smoking
Alcohol
Advancing Age
P.O. Box 1880, Evans, GA 30809
Toll Free: 1-866-692-6676
Fax: 1-706-210-4740
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5 Easy Steps To Complete Your Order
Covered By Medicare & Most Insurance
FDA REGISTERED
1
BENEFITS OF VACUUM THERAPY
The complete
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MODEL 1001
System Includes:
• RX Vacuum Unit
• Deluxe Travel Pouch
• 10 Different Sizes of Tension Systems
(1 (TS) lasts up to three years!)
• Service Oil
• Personal Lubricant - 4oz.
• Simple User Instructions
This product carries a 30 day Satisfaction Guarantee with
an EXCHANGE option in addition to a 5 year FREE
Replacement Warranty on the Vacuum unit against defects.
OR
OTC CUSTOM
Recommended by physicians
because it has clinically proven to be:
Name _________________________________________
Address _______________________________________
City____________________ State_______ Zip ________
EFFECTIVE for more than 90% of men; the Vacurect™
can be applied successfully, regardless of the cause of ED.
Phone (______)_________________________________
SAFE unlike medication or surgery, vacuum therapy uses
only natural erection processes without any side effects.
Birth Date _____________________________________
IMMEDIATE produces an erection suitable for
2
E-mail _________________________________________
intercourse in less than 60 seconds.
Medicare/Primary Policy # ________________________
CONTROLLABLE the patient determines when,
how long, and how often he wants intimacy.
Secondary Insurance Name _______________________
Phone (______)_________________________________
CONSISTENT the same erection each and every time,
regardless of other physical and/or physiological factors.
Policy # _______________________________________
COST EFFECTIVE little (or no) cost compared to
3
™
MODEL 1002
other treatments.
I authorize the equipment supplier
to file for my insurance benefits for my purchase*
System Includes:
• OTC Vacuum Unit
Signature Required.
• Storage Sleeve
• 5 Different Sizes of Tension Systems
Patient Signature
• Personal Lubricant - 2oz.
• Simple User Instructions
This product carries a 30 day 80% Money Back Satisfaction
Guarantee in addition to a 1 year FREE Replacement
Warranty on the Vacuum unit against defects.
*You are responsible for paying Bonro Medical, Inc. the total
amount of your unmet Medicare deductible or any amount not
covered by your insurance. Medicare cannot have purchased
a VED within the last 5 years. You must sign and date the
Assignment of Medicare Benefits Section (Above).
Mailing Address:
P.O. Box 1880, Evans, GA 30809
Business Address:
4490 Washington Rd., Bldg. 100, Ste 16, Evans, GA 30809
Toll Free 1-866-692-6676 Fax: 1-706-210-4740
www.BONRO.com
Date
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www.BONRO.com
Flip OveR
Cont.
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Name _________________________________________
Address _______________________________________
Suite __________________________________________
City____________________ State_______ Zip________
SAFE, SIMPLE,
COMPACT, EFFECTIVE
& FDA REGISTERED
Approved by Medicare
& Most Insurance
HOW THE
Vacurect™
Step 1
Attach the tension system
to the base of the cylinder
by pressing firmly.
Toll Free 1-866-692-6676
www.BONRO.com
Step 2
Apply a dime size amount
of personal lubricant on
the index finger and apply
to the glans head of the
penis. Apply the excess
lubricant to the opening
of the tension system.
Phone (______)_________________________________
Fax
(______)_________________________________
Specialty ______________________________________
My patient has been diagnosed with Organic Impotence
(Code-607.84) as a result of the following condition(s):
PLEASE CHECK ALL THAT APPLY:
185 Carcinoma of the Prostate
401.9 Hypertension
188.9 Carcinoma of the Bladder
952.9 Spinal Cord Injury
443.9 Peripheral Vascular Disease
154.0 Colorectal Cancer
Step 3
Gently rest the tip of the
penis in the opening of
the tension system.
250.00 Non-Insulin Dependent Diabetes Mellitus
Step 4
250.01 Insulin Dependent Diabetes Mellitus
Move the sleeve up and
down the cylinder to
create the vacuum; this
will draw the penis
through the tension
system into the cylinder.
Other:
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Doctor Signature
Date
NPI# __________________________________________
OR
Step 5
After creating the erection,
remove the cylinder from
the tension system, leaving
the tension system in place
at the base of the penis.
If your insurance does NOT cover Vacuum Therapy you can purchase the
OTC CUSTOM™ MODEL 1002
(Over-The-Counter)
VACUUM DEVICE (OTC), $195.00
Plus US $14.95 USPS Priority Shipping & Handling
(Delivery outside of the USA is an additional charge)
VACURECT service oil $7.00
Visa
Mastercard
Discover
Check/Money Order (GA Residents Add 7% Tax)
CVV code
MM
Name as Appears on Card
VACUUM THERAPY
THE PRACTICAL SOLUTION
Although other treatments for ED (e.g. Viagra®, Injections and Penile implants) are
widely used today, Vacuum Therapy is gaining increasing popularity by patients and
their physicians because of the very positive associated benefits. In fact, Vacuum
Therapy should be used as a daily exercise to prevent atrophy and to promote penile
health. Evidence from leading urologists promotes the idea that this treatment
improves penile health by restoring adequate blood flow and revitalizing vascular
tissues.
THE VACURECT™
THE ULTIMATE IN VACUUM THERAPY
Card Number
Expiration Date
WORKS
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Signature
The Vacurect™ is setting a new standard in vacuum therapy, and has already restored
thousands of relationships. The Vacurect™ is compact, efficient, and simple to operate.
It uses a natural pumping action that does not detract from natural intimacy. The
Vacurect™ uses a unique double-sealing Tension System that ensures maximum
efficiency. Even better, the Vacurect™ comes with 10 Tension Systems of different
sizes that last up to three years (no costly Tension Systems to buy every 3 months!)
OR
COMPETITOR’S VACUUM
ERECTION DEVICES
VACURECT™
ONE PIECE DESIGN
Other Vacuum Pumps typically are
bulky, cumbersome, hard to incorporate
during foreplay and not sexually
appealing. These qualities proved to be
significant drawbacks to the advancement of vacuum therapy among patients.
The Vacurect™ is the first and only system
that allows you to enjoy the benefits of
Vacuum Therapy without the drawbacks.
The Vacurect™ is one-piece, easy to use,
very compact, and always reliable.
view our
INSTRUCTIONAL VIDEO
on our website
www.BONRO.com
Covered by Medicare & Most Medical insurance
i
F more information call us
For
Toll Free 1-866-692-6676
Or visit www.BONRO.com
Mail: P.O. Box 1880
Evans, GA 30809
“For the last five years, my husband and I have been using an
early model vacuum system…it was awkward to include in
our love making and the rings or bands were uncomfortable
for my husband. Now the Vacurect™ has unbelievably
enhanced our intimate moments together.” Clifton, NJ