Guarantee Certificate Please fill in the questionnaire to validate your guarantee Name   (Required) First name   E-Mail   (Required) Address   (Required)   ZIP Code   (Required) Town   (Required) State   Country   Select your countryAFGHANISTANÅLAND ISLANDSALBANIAALGERIAAMERICAN SAMOAANDORRAANGOLAANGUILLAANTARCTICAANTIGUA AND BARBUDAARGENTINAARMENIAARUBAAUSTRALIAAUSTRIAAZERBAIJANBAHAMASBAHRAINBANGLADESHBARBADOSBELARUSBELGIUMBELIZEBENINBERMUDABHUTANBOLIVIABOSNIA AND HERZEGOVINABOTSWANABOUVET ISLANDBRAZILBRITISH INDIAN OCEAN TERRITORYBRUNEI DARUSSALAMBULGARIABURKINA FASOBURUNDICAMBODIACAMEROONCANADACAPE VERDECAYMAN ISLANDSCENTRAL AFRICAN REPUBLICCHADCHILECHINACHRISTMAS ISLANDCOCOS (KEELING) ISLANDSCOLOMBIACOMOROSCONGOCONGO, (DEMOCRATIC REPUBLIC)COOK ISLANDSCOSTA RICACÔTE D'IVOIRECROATIACUBACYPRUSCZECH REPUBLICDENMARKDJIBOUTIDOMINICADOMINICAN REPUBLICECUADOREGYPTEL SALVADOREQUATORIAL GUINEAERITREAESTONIAETHIOPIAFALKLAND ISLANDS (MALVINAS)FAROE ISLANDSFIJIFINLANDFRANCEFRENCH GUIANAFRENCH POLYNESIAFRENCH SOUTHERN TERRITORIESGABONGAMBIAGEORGIAGERMANYGHANAGIBRALTARGREECEGREENLANDGRENADAGUADELOUPEGUAMGUATEMALAGUINEAGUINEA-BISSAUGUYANAHAITIHEARD ISLAND AND MCDONALD ISLANDSHOLY SEE (VATICAN CITY STATE)HONDURASHONG KONGHUNGARYICELANDINDIAINDONESIAIRAN, ISLAMIC REPUBLIC OFIRAQIRELANDISRAELITALYJAMAICAJAPANJORDANKAZAKHSTANKENYAKIRIBATIKOREA, DEMOCRATIC PEOPLE'S REPUBLIC OFKOREA, REPUBLIC OFKUWAITKYRGYZSTANLAO PEOPLE'S DEMOCRATIC REPUBLICLATVIALEBANONLESOTHOLIBERIALIBYAN ARAB JAMAHIRIYALIECHTENSTEINLITHUANIALUXEMBOURGMACAOMACEDONIA, THE FORMER YUGOSLAV REPUBLICMADAGASCARMALAWIMALAYSIAMALDIVESMALIMALTAMARSHALL ISLANDSMARTINIQUEMAURITANIAMAURITIUSMAYOTTEMEXICOMICRONESIA, FEDERATED STATES OFMOLDOVA, REPUBLIC OFMONACOMONGOLIAMONTSERRATMOROCCOMOZAMBIQUEMYANMARNAMIBIANAURUNEPALNETHERLANDSNETHERLANDS ANTILLESNEW CALEDONIANEW ZEALANDNICARAGUANIGERNIGERIANIUENORFOLK ISLANDNORTHERN MARIANA ISLANDSNORWAYOMANPAKISTANPALAUPALESTINIAN TERRITORY, OCCUPIEDPANAMAPAPUA NEW GUINEAPARAGUAYPERUPHILIPPINESPITCAIRNPOLANDPORTUGALPUERTO RICOQATARRÉUNIONROMANIARUSSIAN FEDERATIONRWANDASAINT HELENASAINT KITTS AND NEVISSAINT LUCIASAINT PIERRE AND MIQUELONSAINT VINCENT AND THE GRENADINESSAMOASAN MARINOSAO TOME AND PRINCIPESAUDI ARABIASENEGALSERBIA AND MONTENEGROSEYCHELLESSIERRA LEONESINGAPORESLOVAKIASLOVENIASOLOMON ISLANDSSOMALIASOUTH AFRICASOUTH GEORGIA AND THE SOUTH SANDWICH ISLANDSSPAINSRI LANKASUDANSURINAMESVALBARD AND JAN MAYENSWAZILANDSWEDENSWITZERLANDSYRIAN ARAB REPUBLICTAIWAN, PROVINCE OF CHINATAJIKISTANTANZANIA, UNITED REPUBLIC OFTHAILANDTIMOR-LESTETOGOTOKELAUTONGATRINIDAD AND TOBAGOTUNISIATURKEYTURKMENISTANTURKS AND CAICOS ISLANDSTUVALUUGANDAUKRAINEUNITED ARAB EMIRATESUNITED KINGDOMUNITED STATESUNITED STATES MINOR OUTLYING ISLANDSURUGUAYUZBEKISTANVANUATUVENEZUELAVIET NAMVIRGIN ISLANDS, BRITISHVIRGIN ISLANDS, U.S.WALLIS AND FUTUNAWESTERN SAHARAYEMENZAMBIAZIMBABWE Telephone   (Required) Fax   Height   cm Weight     Kg Pathology :    (.....) Haemiplegic Tetraplegic Paraplegic Reached Miopathy Reached of Sclerosis Other   Chair’s Number :   Power stand-up unit number :   Model :    LSA   LSC   LSH   LSE   LSC KID   LS   LSM   Dealer name :   Dealer adress :      Purchase date :    JJ/     MM/     AAAA (25/12/2001) Is it your first stand-up chair ?    Yes   No   If not what was your old model ?   Change motive :    (.....) worn chair unsuitable chair needs changed Other   Magazine :   Yes   Recommendation of :    (.....) My doctor My physiotherapist My circle   Rehabilitation Center display.    Yes   Exhibition display :    (.....) REHA MEDTRADE OTHER   Internet :   Yes   2) Are our brochures :    very complete   acceptable   inadequate   3) Do our brochures give enough technical informations ?    Yes   No   4) Has your dealer given all details you need ?    Yes   No   5) Did you have a personal evaluation with ?    (.....) your dealer in an exhibition both None   6) Delivery time was about     days 7) Was delivery time :    (.....) Too long delay Poor Normal Excellent   8) Was delivery on day we advised ?    Yes   No   9) Was the chair adjusted for you by :    (.....) your dealer adjusted during the production   10) How do you rate your dealer service ?    (.....) Poor Average Good Excellent   11) Do you use your chair as :    (.....) your every day chair a therapeutic chair both   12) How is your chair manoeuverability ?    (.....) Poor Average Good Excellent   13) How is the chair appearance ?    (.....) Poor Average Good Excellent   14) How do you rate the chairs suspension ?    (.....) Poor Average Pleasant Comfortable   15) When standing up, is your position ?    (.....) Poor Average Easy Excellent   16) When sitting down, is your position ?    (.....) Poor Average Easy Excellent   17) How de you score ease of access to the various functions of the wheelchair ?    (.....) Poorly Well enough Well Outstandingly well   18) How do you score ease of access to the various functions of the wheelchair ?    (.....) Poor Passable Good Excellent   19) How do you score the standing position for comfort ?    (.....) Poor Passable Good Excellent   20) How do you score the recumbent position for comfort ?    (.....) Poor Passable Good Excellent   21) How do you score the relax position for comfort ?    (.....) Poor Passable Good Excellent   22) How do you score the user-friendly couchette position for comfort ?    (.....) Poor Paasable Good Excellent   23) Is your chair in accordance with your wishes ?    Yes   No   24) Have you ever used the After-Sales Service ?    Yes   No   If yes, was that?    (.....) satisfactory average inadequate   Please write other comments here. For exemple : What is the chair best feature ; What disappointed you in this chair ; Which parts or functions could be improved, and how ?