Warranty Form

Serial Number*
Method of Payment
If other, list Payment Method*
Date of Purchase*
MM slash DD slash YYYY
Was this product purchase for:
Name*
First Last
Day Phone Number
Email*
Primary Address
Address Type
Address
Street Address City State / Province / Region ZIP / Postal Code Country
Is this your first stander?
- Yes
- No
If no, what brand was your stander?
Active Dealer
Company
Name of ATP
First Last
Address
Street Address City State / Province / Region ZIP / Postal Code Country
Phone
Facility
Dr. or Therapist who prescribed your stander
Name of Prescribers Facility
Address
Street Address City State / Province / Region ZIP / Postal Code Country
Phone
How did you hear about Easy Stand products?
What contact did you have with EasyStand prior to purchase?
How likely is it that you would recommend/prescribe Easystand products to a friend/client?
What words would you use to describe our products? Our customer service?
What health and psychological benefits do you feel you receive the most from standing?
Why did you choose a stander from EasyStand? What did you like best about it?
You have my permission to quote my comments & use these quotes in ads, brochures, mail and other promotions used to market your products.
- Yes
- No
*this warranty registration form is intended for United States customers only.
CAPTCHA

Primary Address