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:
Institution:
Street Address / P.O. Box:
Address2:
City:
State/Prov:
Postal Code/ZipCode:
Country:
Daytime Phone:
Fax Number:
Email:
Can we contact you about future research or product improvements?
 Yes   No
Where did you hear about INRatio?
 Sales rep
 Advertisement
 Direct Mail
 Referral/Friend
 Trade Show/Event
Other:
Are you a:
 Cardiologist
 Family/General Practice
 Pharmacist
 Internal Medicine
Other:
How many Coumadin patients do you manage?
 Less than 10
 10-20
 20-50
 50-100
 Over 100
Did you visit www.hemosense.com before today?
 Yes   No
How did you test INR before INRatio?
 Sent patients to lab
 Used a different POC analyzer:
Brand:
When did you purchase the INRatio Meter?

 
What is the Serial Number on your INRatio? (REQUIRED)
(9 digit number beneath the barcode on the bottom of your monitor)
I purchased or received my INRatio from:

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