3 month Warranty Form Healthmate Forever

Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
E-mail*
Store/Seller Name*
Order ID/Receipt #*
Date of purchase*

MonthDayYear
Purchase Price*
Model/Serial Number*
Where did you hear about this product?

Received as a giftInternetFriend/Family RecommendationSalesperson's ReommendationFlyer/BrochureTrade ShowOther
Date of Birth

MonthDayYear
Where was product purchased?

Healthmateforever.comAmazonTrade-showReceived as GiftOther
How often do you use this product?

Daily1-3 times a week3-6 times a weekOnce a weekOther
Which warranty do you have?

90 Day Warranty2 Year WarrantyLimited Lifetime Warranty
2 Year Warranty Code:
Invoice/Receipt

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