Method of purchase: (check all that apply) Medicare Medicaid Insurance Other: This product was purchased for use by: (check one) Self Parent Spouse Other: This product was purchased for use at: (check all that apply) Home Facility Other: I purchased a Per4max product because: (check all that apply) Price Features(list): Who referred you to Per4max products? (check all that apply) Doctor Therapist Friend Dealer/Provider Newspaper Magazine Friend No Referral Other: What additional features, if any, would you like to see on this product? Would you like to receive information about Per4Max products that may be available for a particular medical condition? Yes No If yes, please list any condition(s) here and we will send you information by email and/or mail about any available Per4Max products that may help treat, care for or manage such condition(s): Would you like to receive updated information via email or regular mail about the Per4Max medical products sold by Per4Max dealers? Yes No What would you like to see on the Per4Max website?
