Trudell Medical | Device Registration

First Name *

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Last Name *

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Email Address *

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Address *

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City *

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Province *

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Postal Code *

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Who uses this product? *

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Name of the user

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What year was the user born? *

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Device is used for treatment of:

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Whose recommendation influenced you to use the device as part of your treatment? *

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Was the cost of the device covered by any of your insurance programs? *

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