Product Information

Please enter information for your product below. Fields highlighted in yellow are required. If you have any questions, please call Midmark Customer Service at 1-800-MIDMARK.

Product

Please select the product which was purchased

Purchase Information

Please enter information regarding your purchase.

Contact Information

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Email Address

Your warranty registration details will be sent to this email address upon submission of this form.

Physician or Facility Name and Address

Physician Phone Number

Purchase Information

Please enter information for your product below. Fields highlighted in yellow are required. If you have any questions, please call Midmark Customer Service at 1-800-MIDMARK.

How important were the following in your business decision?

Brand's Reputation for Reliability
Clinically Proven Equipment
Quality Construction
Affordability
Nationwide Support
Clinican Recommended
Usability

Did you plan to expand or remodel your practice or build a new practice in the next 18-24 months?

Did you plan to expand or remodel your practice or build a new practice in the next 18-24 months?

Did you plan to purchase any of the following products in the next 18-24 months?

Did you plan to purchase any of the following products in the next 18-24 months?










How were you introduced to Midmark equipment?

Select all that apply.
How were you introduced to Midmark equipment?






Which other brands or models did you consider/What made you choose our product over others?

Do you have any recommendation for improving our equipment or expanding our product line?

Would you recommend our equipment to other practitioners?

Would you recommend our equipment to other practitioners?

Additional comments?

Occasionally, we use customer comments in our promotional materials. Is it okay if we use your comments?

Occasionally, we use customer comments in our promotional materials. Is it okay if we use your comments?

Demographics

Please enter information for your product below. Fields highlighted in yellow are required. If you have any questions, please call Midmark Customer Service at 1-800-MIDMARK.

Which of the following best describes your practice?

Select all that apply.
Which of the following best describes your practice?













How many of the following does your practice have?

Review

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