Patients Professionals Investors Distributors
INRatio Warranty Registration Form

HemoSense is dedicated to making PT/INR testing as simple and convenient as possible. Please help us in this effort by taking a few moments to share your thoughts and some information about you.

All information will be kept confidential.

First Name:
Initial:
Last Name:
Street Address / P.O. Box:
Address2:
City:
State/Prov:
Postal Code/ZipCode:
Country:
Daytime Phone:
Fax Number:
Email:
It's OK to contact me via email
 Yes   No
Your Age:
 0-18
 19-24
 25-34
 35-44
 45-54
 55-64
 65-74
 75+
Gender:
 Male   Female
Your Indication:
 Heart Valve
 Atrial Fibrillation
 Heart Attack
 Deep Vein Thrombosis
 Stroke
Other:
Do you have any form of reimbursement or insurance coverage for your monitor and/or supplies?
 Yes   No
How long have you been taking Coumadin/warfarin?
 years
Which statement represents the most accurate reason why you chose INRatio?
 Latest Technology
 Easiest to Use
 Accuracy/Reliability of Results
 Advanced Quality Controls
 Smallest Device
 Most Convenient

Recommended by:
Can we contact you about future research or product improvements?
 Yes   No
Would you like to receive an INRatio instructional video?
 DVD   VHS   No Thanks
How did you test your PT/INR before INRatio?
 I went to a Lab
 I tested at my Doctor's Office
 I used a different home test monitor
Brand:
When did you start using the INRatio Meter?

 
What is the Serial Number on your INRatio? (REQUIRED)
(9 digit number beneath the barcode on the bottom of your monitor)

For more information about HemoSense or the INRatio Monitor, please contact us.
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