Invacare X-Terminator QR Wheelchair User Manual


 
Part No 1114851 7 Everyday and Sport Series Wheelchairs
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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