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SPECTRA THERAPY, LLC.
5832 Glasgow Drive
Troy, MI 48085

If you fail to complete the product registration form below, your warranty rights as otherwise specified will not be diminished.

Please visit http://spectratherapy.com/privacy/ for privacy policy.

Product Registration Form

Name:*

First

Last

Middle

E-mail:*

Phone:*

Area Code

-

Phone Number

Address:*

Street AddressStreet Address Line 2CityState / Province / RegionPostal / Zip CodeAfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiaComorosCongo (Brazzaville)CongoCosta RicaCote d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast Timor (Timor Timur)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint VincentSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbia and MontenegroSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamYemenZambiaZimbabweCountry

Purchased Spectra Therapy Products (Check all that apply):*

LASERwrap® U Wrap - Regular

LASERwrap® U Wrap - Large

LASERwrap® Conical Tall Wrap

LASERwrap® Conical Short Wrap

LASERwrap® Multi-Purpose Pad

LASERwrap® Dual Filament Strip 40"

LASERwrap® Dual Filament Strip 24"

LASERwrap® Dual Filament Strip 12"

LASERwrap® Bed Pad

LASERwrap® Vest

LASERwrap® Shoulder Wrap

Intraoral Device

Accessories (Enter below)

Other (Enter below)

Other accessories or products purchased that are not listed above:

Number of Lasers:*

Model: (Check all that apply)*

A-100

Other (Enter below)

Other Models:

Serial Number(s) (Place comma's between each serial number if more than one):*

Purchased Date:*

Purchased from?*

Sales Contact (ENTER NAME):

How did you hear about Wearable LASERwrap®? (Check all that apply)*

Healthcare Professional

Recommended by a friend or acquiantence

Email

Catalog

Website

Facebook

Online Search

Trade Show

Magazine Add

Forum

Other (Enter below)

Other:

About You

Your Gender:*

Female

Male

Age Range:*

29 years old or under

30 to 49 years old

50 or more years old

Are you a healthcare professional?:*

Yes

No

If you answered "Yes" to healthcare professional, enter your specialty:

Occupation/Profession (Check all that apply):

Doctor

Surgeon

Chiropractor

Dentist

Oral Surgeon

Physical Therapist

Massage Therapist

Accupuncture Therapist

Other (Enter below)

Other Occupation/Profession:

Company Name (If applicable):

Company Address:

Street AddressStreet Address Line 2CityState / Province / RegionPostal / Zip CodeAfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiaComorosCongo (Brazzaville)CongoCosta RicaCote d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast Timor (Timor Timur)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint VincentSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbia and MontenegroSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamYemenZambiaZimbabweCountry

Work Phone:*

Area Code

-

Phone Number

Work E-mail:

Website:

Number of other healthcare professionals are in your office? :*

About your purchase

Do you own other therapy devices?*

Yes

No

If yes to the previous question, please list the devices or technologies that you own or use:

What were the most important reasons you purchased Spectra Therapy LASERwrap®? (Check all that apply)*

General conditioning and health maintenance

Performance improvement

Have on hand in the event an injury or illness occurs

Professional use

Professional use

Injury?

Chronic Conditions(s)

Other

If you checked "Injury","Chronic conditions", or "other" to the prvious question, can you please explain in further detail?

Why did you purchase a Spectra Therapy LASERwrap® kit over other therapy devices? (Check all that apply)*

Ease of use

Automatic feature

Effectiveness

Drug free

Wearable

Portable

No cords, wires, gels

Price

Other

If you selected "Other" to the previous question, plesae explain in further detail:

Are you interested in receiving information about extended warranty and protection plans?*

Yes

No

Do you want to receive product announcements?*

Yes

No

Do you want to receive information on special promotions?*

Yes

No

Are you interested in learning about becoming a distributor and/or offering the Spectra products for sale in your office or business?*

Yes

No

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