Alpha-Stim

Celebrating 27 years
1981-2008

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EPI

2201 Garrett Morris Parkway
Mineral Wells, TX 76067-9034
USA
1-800-FOR-PAIN (367-7246)
in USA & CANADA
Tel: (940) 328-0788
Fax: (940) 328-0888
Email

Alpha-Stim® is registered in the US Patent and Trademark office and worldwide.

US Government Federal Supply Schedule
Contract Number for DOD and VA: V797P-4800a

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

Check one:

practitioner purchasing for practice patient purchasing for self

Name

If practitioner, degree and specialty

Name of clinic or hospital where Alpha-Stim is used

Address

City

State or Province

Country

Postal Code

Phone

Fax

Purchased From

Purchased 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: M F

How long have you been using the Alpha-Stim?

Have you: completed Treatment still using it discontinued it because

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