Online Warranty & Registration Form

Physician Name:	A name is required.
Title:	A title is required.
Institution:	Institution is required.
Address 1:	Address is required.
Address 2:
City:	A city is required.
State:	A state is required.   Zip/Postal code: A code is required.
Country:	A country is required.
Business Phone:	A phone is required.
Email:	Email is required.
Date of Purchase:	Date is required.
Serial Number:	A serial number is required.
Physician Specialty:
Suggestions/Comments

Please rank in order (1 being the highest) the reasons you bought the headlight:

• 1 2 3 4 5 Light Quantity / Intensity
• 1 2 3 4 5 Maintenance Ease
• 1 2 3 4 5 Light Quality
• 1 2 3 4 5 Cordless Convenience
• 1 2 3 4 5 Cost Effectiveness
• Other:

Where will the headlight be used? (please check all that apply):

• Operating Room
• Clinic
• Surgery Center
• Office
• Other

How did you learn about the headlight?:

Meeting Sales Rep Website	Colleague Mailing Conference
Other

How would you rate your experience using the headlight?:

• exceeds
• meets
• does not meet

If you purchased a battery pack, please indicate:

• B2X Battery pack
• B4X Battery pack
• S/N:

Enter Security Code: