Guarantee Certificate
Please fill in the questionnaire to validate your guarantee
Name   (Compulsory)
First name  
E-Mail   (Compulsory)
Address   (Compulsory)
 
ZIP Code   (Compulsory)
Town   (Compulsory)
State  
Country  
Telephone   (Compulsory)
Fax  
Height   cm
Weight :    Kg
Pathology :     
Chair’s Number :  
Power stand-up unit number :  
Model :    LSA  
Dealer name :  
Dealer adress :  
   Purchase date :    JJ/     MM/     AAAA (25/12/2001)