Part No.1125095
5
Transport Chairs
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
❏
Medicaid
❏
Other
__________________________
2.
This product was purchased for use by: (check one)
❏
Self
❏
Parent
❏
Spouse
❏
Other
3.
Product was purchased for use at:
❏
Home
❏
Facility
❏
Other
4.
I purchased an Invacare product because:
❏
Price
❏
Features (list features) _________________________________________
5.
Who referred you to Invacare products? (check all that apply)
❏
Doctor
❏
Therapist
❏
Friend
❏
Relative
❏
Dealer/Provider
❏
Other_________
❏
Advertisement (circle one): TV, Radio, Magazine, Newspaper
❏
No Referral_____
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?
❏
Yes
❏
No
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 Invacare
home medical products sold by Invacare's dealers?
❏
Yes
❏
No
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?
❏
Yes
❏
No
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.
PRODUCT REGISTRATION FORM
Register ONLINE at www.invacare.com - or -
Complete and mail this form
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