Wufoo

Product Registration Form

Consumer/Augmented Communicator
Name * First Last
Please enter your name
Male Female
Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Work Phone - (###) - ### ####
Home Phone * - (###) - ### ####
Email *
Primary Contact if Different
Name First Last
Contact Phone Number
Email
Referring Clinician
Relationship to Customer
Spouse Parent SLP Special Educator Professional Caregiver Other
If Other Please Specify
Product Information
DynaVox Device Model *
V Vmax EyeMax M3 Palmtop3 DynaWrite Lightwriter SL38 Lightwriter SL87 LightwriterSL88 Boardmaker Activity Pad
Product Serial Number *
Why Did You Choose This Product? (Please select up to three) *
Device Weight Battery Life Product Cost Clinician Recommendation Friend Recommendation Educator Recommendation Product Quality Satisfaction with other DynaVox Products Product Features Ease of Use/Programming Successful Trial Other
If Other Please Specify
Customer Information (optional)
Age of User
Is Augmented Communicator currently in school.
Yes No
Diagnosis Category
Amyotrophic Lateral Sclerosis Autism Spectrum Disorder Cerebral Palsy Cerebral Vascular Accident (Stroke) Developmental Delay Laryngentomy Traumatic Brain Injury Other
If Other Please Specify
How does the augmented communicator compose messages?
Symbols only Text only Symbols and Text
Device Access Method (please check all that apply)
Dual Switch Scanning Head Pointer Head Tracker/HeadMouse Keyboard Morse Code Single Switch Scanning Touch Screen Touch Screen with Keyboard
Is the device mounted to a wheelchair or bed?
Yes No
How did you first learn about this product?
Article in Magazine or Newspaper Broadcast News Story DynaVox Product Literature DynaVox Product Advertisement DynaVox Sales Representative Neurologist Occupational Therapist Physical Therapist Primary Care Physician Relative or Friend Speech-Language Pathologist Special Education Teacher Web Search Website
Are you interested in DynaVox Technologies Online Training Opportunities?
Yes No
Are you interested in Receiving our DynaVox Connections Newsletter?
Yes No
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Wufoo

Product Registration Form

Consumer/Augmented Communicator

Primary Contact if Different

Product Information

Customer Information (optional)