CIVCO Product Warranty Validation Form

Provide the information below to validate your product warranty.  When finished, please click the "Send Form" button to complete your product warranty validation.

* Required information
First Name: *
Last Name: *
Title:
Department:
Facility: *
Address: *
City: *
State: *
Zip Code: *
Country: *
E-mail Address: *
Phone Number: *
Fax Number: *
PURCHASE INFORMATION
Product Model: *
Date Purchased: *
Reference Number: *
Lot Number: *
How did you learn about CIVCO's products:
 Advertisement
 Tradeshow
  CIVCO Catalog
 Program™
  Committed Campaign
 Website
  OEM Referral
 Other
Select top three criteria considered when purchasing ultrasound accessories:
 Brand or Company Reputation
 System Compatability
 Ease-of-Operation/Use
 Manufacturer Recommendations
 Product Warranty
  Quality Customer Service
 Delivery Time
 Functionality/Design
 Product Reliability
 Price
What ultrasound system(s) do you currently use:
 ALPINION
 Esaote
 Hitachi Aloka Medical
 Philips
 SonoSite
 Toshiba
 Other
  B-K Medical
 Fukuda
 SAMSUNG Medison
 Shimadzu
 SuperSonic Imagine
 Ultrasonix
  Chison
 GE Healthcare
 Mindray
 Siemens
 Terason
 Zonare
Please keep me updated about new products by:
 Catalog
 Email
  Direct Mail
 Phone Call