Product Registration Form - Invacare Top End T-3 Tennis Adjustable Operating And Maintenance Manual

PRODUCT REGISTRATION FORM

Register ONLINE at www.invacare.com - or -
Name _______________________________________________________________
Address _____________________________________________________________
City ____________________State/Province ___________
Zip/Postal Code _________
Email ___________________________________ Phone No. _________________
Invacare Model No. ______________________ Serial No. __________________
Purchased From _________________________ Date of Purchase: ___________
1. Method of purchase: (check all that apply)
Medicare Insurance
2. This product was purchased for use by: (check one)
Self Parent
3. Product was purchased for use at:
Home Facility
4. I purchased an Invacare product because:
Price Features (list features) ________________________________________
5. Who referred you to Invacare products? (check all that apply)
Doctor Therapist
Advertisement (circle one): TV, Radio, Magazine, Newspaper
6. What additional features, if any, would you like to see on this product?
__________________________________________________________________________
7. Would you like information sent to you about Invacare products that may be available for
a particular medical condition?
If yes, please list any condition(s) here and we will send you information by email and/or mail
about any available Invacare products that may help treat, care for or manage such condition(s):
__________________________________________________________________________
8. Would you like to receive updated information via email or regular mail about the Invac-
are home medical products sold by Invacare's dealers?
9. What would you like to see on the Invacare website?
__________________________________________________________________________
10. Would you like to be part of future online surveys for Invacare products?
11. User's Year of birth: ______________________________________________________
If at any time you wish not to receive future mailings from us, please contact us at Invacare Corporation,
CRM Department, 39400 Taylor Parkway, Elyria, OH 44035, or fax to 877-619-7996 and we will
remove you from our mailing list.
To find more information about our products, visit www.invacare.com.
Complete and mail this form
Medicaid Other
Spouse Other
Other
Friend Relative
Yes No
__________________________
Dealer/Provider Other_________
No Referral_____
Yes No
Fold
here
Fold
here
Yes No