Invacare Atlas manual Product Registration Form, City State/Province

Cut Along Line

PRODUCT REGISTRATION FORM

Register ONLINE at www.invacare.com - or -

Complete and mail this form

Name _______________________________________________________________
Address _____________________________________________________________
City ___________________State/Province __________
Zip/Postal Code ________
Email ___________________________________ Phone No. _________________					Fold
Invacare Model No. ______________________ Serial No. __________________					here
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?

__________________________________________________________________________ Fold

7.	Would you like information sent to you about Invacare products that may be available for a here
	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.

Part No. 1130169 5 Atlas™