Alpha-Stim

Registration Information

Register your product to insure warranty coverage under EPI’s 5 Year Limited Warranty (Previously Owned Quality Assured Alpha-Stim‘s receive a 1 Year Limited Warranty).

Check type of unit (check one only):

Alpha-Stim 100 microcurrent & cranial electrotherapy stimulator
Alpha-Stim SCS cranial electrotherapy stimulator
Alpha-Stim PPM microcurrent stimulator

Serial Number

Contact Information

Check one:

practioner purchasing for practice patient purchasing for self

Name

If practioner, degree and specialty

Name of clinic or hospital where Alpha-Stim is used

Your Address

Address

City

State or Province

Country

Postal Code

Phone

Fax

Email

Purchased from

City

Purchase date

How did you learn about the Alpha-Stim 100, Alpha-Stim SCS or Alpha-Stim PPM?

Questionaire

The following optional, voluntary information would be appreciated and will help in our ongoing research. Please fill in after 30 days of use.

What is your diagnosis?

What is your age?

Sex: M F

How long have you been using the Alpha-Stim?

Have you: completed Treatment still using it discontinued it because

How would you rate the results so far? (check one box only):

Worse (negative change)
No change (0%)
Slight Improvement (1 to 24%)
Fair Improvement (25 to 49%)
Moderate Improvement (50 to 74%)
Marked Improvement (75 to 99%)
Complete Recovery (100%)

Would you consider the Alpha-Stim to be (check all that apply)

safe
effective
ineffective