Invacare ROLLITE 65100 Manual Del Usario página 21

1. Method of purchase: (check all that apply)
Medicare Insurance
2. This product was purchased for use by: (check one)
Self Parent
3. Product was purchased for use at:
Home Facility
4. I purchased an Invacare product because:
Price Features (list features)
5. Who referred you to Invacare products? (check all that apply)
Doctor Therapist
No referral Advertisement (circle one): TV, Radio, Magazine, Newspaper
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?
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?
_________________________________________________________________
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
Medicaid Other
Spouse Other
Other
Friend Relative
Yes No
Yes
www.invacare.com.
Other
No