Invacare BUZZ HMV PRODUCT REGISTRATION FORM, Name, Address, Purchased From, Zip/Postal Code, Complete and mail this form, City ___________________State/Province

Detach here

PRODUCT REGISTRATION FORMRegister 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 _____________________________________________________
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 ❏ Other ___________________

❏No referral ❏ Advertisement (circle one): TV, Radio, Magazine, Newspaper

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.