RESPeRATE Warranty Registration Form

Warranty Registration Form

First Name

Last Name

Address

City

State

Zip

Country

Phone

Fax

E-mail Address

Serial # (Found on bottom of device)

Date of Purchase

Place of Purchase

RESPeRATE invites you to answer the following questions, to allow us to better serve our customers.

How did you first learn about RESPeRATE ?

Did you consult your physician prior to purchasing RESPeRATE ?

Yes No

Your approximate household income is :

35,000$-49,000$ 50,000$-74,999$ 75,000$-99,999$ 100,000$ or more