Personal Information Name * Address * Sex * SelectMaleFemale Birthdate * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year19651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017201820192020202120222023202420252026 Civil Status * SelectSingleMarriedWidowSeparatedComplicated Profession Phone No * Mobile No * Email * Product Information Brand Name * Model No. * Serial No. * Place of Purchase * Date of Purchase * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year202320242025 Place of Installation * SelectHomeHospitalMedical ClinicOthers Photo of Proof of Purchase (receipt/invoice) Upload More informationFiles must be less than 2 MB. Allowed file types: gif jpg jpeg png pdf doc docx odt ppt pptx. Wellness PRO invites you to answer the following questions, to allow us to better serve our customers in the days to come: How did you first learn about Wellness PRO Products? Friends and Family Flyers and Brochures Newspapers Received an Email Received a Fax Search Engine Result Saw in booth display Others How did you first learn about Wellness PRO Products? Others What is the reason why you purchased this product It was on sale I trust its quality It is best for my needs I have no other choice Others What is the reason why you purchased this product Others Do you have other products that were previously bought from Wellness PRO? No If yes, please specify Do you have other products that were previously bought from Wellness PRO? If yes, please specify Would you like to receive notifications via e-mail, text, fax, etc. regarding our new products and promos? * Yes No Submit Warranty Registration
