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

practioner purchasing for practice  patient purchasing for self

Check one:

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
Day 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:

Female

Male

How long have you been using the Alpha-Stim?

Have you:	completed treatment, or	still using it, or	discontinued it because
(specify):

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
more effective than anything else you have ever used for your pain
more effective than anything else you have ever used for your anxiety
more effective than anything else you have ever used for your depression
more effective than anything else you have ever used for your insomnia
more effective than anything else you have ever used for your (specify)

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