Authorization to Purchase the Fisher Wallace Stimulator® – This website is owned and operated by Fisher Wallace Laboratories, LLC

Full Name *

Email *

Do you have a medical device implanted in your head or neck? *

Do you have a pacemaker? *

Are you 21 years of age or older? *

May the manufacturer email you important device related updates? *

Confirm that you are not a bot *

1	Answer the questions below to find out if you qualify to use the device.
2	If you qualify, a licensed healthcare practitioner can provide same-day authorization for a fee of $18. Your authorization will be emailed to you and Fisher Wallace. Fisher Wallace does not employ or compensate practitioners for authorizations, nor does it receive any portion of their fee.
3	Purchase a device on www.fisherwallace.com. Fisher Wallace will match your order to your authorization and ship your device on the same or next business day.