Myself, Pelvic Muscle Trainer: Register Myself

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(Select One) Mr.,Mrs.,Ms.,Miss
Name: First & Last	*
Address:
City:
State
Zip		(ex. 97701)
Phone:		(ex."541-123-4567")
Email:	*	(ex."joe@domain.com")

1. Level of Education:(Highest level completed)		High School College Graduate School Other

2. Annual Household Income:		<$20,000 $20,000-$59,000 $60,000-$100,000 >$100,000

3. Device Serial Number	*
4. Date of Purchase:
5. Place of Purchase:

6. Primary Interest in Product:		Bladder Control Sexual Enhancement Pregnancy Toning

7. Factors that Most Infuenced Purchase:		Advertising Friend/Relative Price Style/Appearance Product Features Warranty Other

8. How You Became Aware of MYSELF:		Internet Advertisement Health Practitioner Product in Store Friend/Family Other

9. Preferred Method of Shopping:		Store Internet Catalog Other

10.What Magazines Do You Subscribe To Or Read Frequently?:

11. Interest/Activities You Enjoy Reguarly:		Exercise Travel Home Workshop/Do It Yourself Health/Natural Foods Self-Improvement

Deschutes Medical Products: Register Myself