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| Are you a: |
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| If Other: |
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| Are you mostly interested in: |
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| Name: |
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| Title or Diagnosis: |
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Address:
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City:
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State or Province:
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Zip Code:
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Phone:
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Day or
Evening
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Email:
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Send me the monthly "Standing Room Only" Newsletter
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| How did you hear about EasyStand? |
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If Other:
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| Promo Code: |
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Who is your DME equipment supplier (who did you buy
your wheelchair from)?
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| Free Demonstration Request * |
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Please have an EasyStand representative contact
me regarding trying a stander.
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Do you have specific product(s) and option(s)
that you would like to try?
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What is the best day, time and method of reaching you?
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If you are a consumer, would you like us to
contact someone on your "team"
(i.e. therapist, doctor, supplier, or caregiver)
about arranging the trial? If so, please provide
details.
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Literature and Video Request
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Product Catalog
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U.S. Retail Pricebook and Order Forms
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Product DVD
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"Life After SCI" DVD
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Funding Guide to Standing Technology
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Benefits of Standing Poster (great for clinicians)
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Standing 101 Home Study Course (great for clinicians)
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Credit Application (suppliers only)
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Other:
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Other questions, comments?
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Fields in bold are required.
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View our privacy statement.
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* A note about EasyStand product demonstrations:
If you are a clinician, funding source, or supplier
who would like an in-service, the local independent
rep can arrange to bring EasyStand products to your
facility. If you are a consumer, talk to your team
(therapist, supplier, caregiver) about trying an
EasyStand.
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