Product Registration

Type of unit

Serial Number*

Name*

First Last

Customer Type

If practitioner, degree and specialty

Address*

Street Address Address Line 2 City Province Postal Code

Phone*

Email*

Name of clinic or hospital where Alpha-Stim is used

Purchased From

Purchased in City

Purchased Date*

How did you learn about the Alpha-Stim?

Would you recommend Alpha-Stim to friends and family?

The following optional, voluntary information would be appreciated and will help in our ongoing research. Please fill in after 30 days of use.

What is your diagnosis?

How long have you been using your Alpha-Stim?

What is your age?

What is your gender?

Anxiety:

Insomnia:

Depression:

Pain:

Other (Please specify):

Did you have any side-effects from using Alpha-Stim?

If yes, please specify.

Provide any additional comments here.

Comments

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