Online product registration form.

Product Information

Do you read the following publications:
 New Mobility
 Mobility Management

 Rehab Management


What is your diagnosis?
 Cerebral Palsy
 Mutiple Sclerosis
 Polio
 Paraplegic
 Muscular Dystrophy
 Head Injury

 Tetraplegic (Quadriplegic)
 Amputee
 Hemiplegic
 Arthritis
 Spina Bifida
 Other

Place of purchase information

How did you find out about Amysystems?
 Therapist
 Supplier
 Advertisement

 Friend
 Reputation
 Tradeshow

Primary use of your wheelchair?
 Everyday Mobility
 Sports

 Work


Is this your first chair?
 Yes

 No

If no, who was the manufacturer and what model was your previous chair?

Would you like us to email you with product information, maintenance tips, and News?
 Yes

 No