Rent a BCX Ultra Deluxe Rife Machine

Renter Name *

First Name

Last Name

Renter Phone (for Country enter Phone Contry Code - ie. 1 for Canada and the US) *

Country

(###)

###

####

Renter

Other Name 1

First Name

Last Name

Other Name 2

First Name

Last Name

Other Name 3

First Name

Last Name

Initial Rental Period *

1 Week - $150 CAD + HST / $125 USD

2 Weeks - $300 CAD + HST / $250 USD

3 Weeks - $450 CAD + HST / $375 USD

4 Weeks - $600 CAD + HST / $500 USD

Ray Tube Breakage Protection

For the replacement of up to 1 Ray Tube during Rental Period:

1 Week - $9 CAD + HST / $7 USD

2 Weeks - $18 CAD + HST / $14 USD

3 Weeks - $27 CAD + HST / $21 USD

4 Weeks - $36 CAD + HST / $28 USD

Waitlist Request

I would like to be on the Waitlist, understand I will be billed the Initial Rental Period amount and that the amount will go towards my Initial Rental Period once I receive the machine.

*

As the Renter, I agree the information above is correct, agree to the Terms & Conditions, will inform the Person(s) who will use the machine of the Terms & Conditions, and if I am not the user have the authority to agree to and submit this information on their behalf.