NexDose® User
Name:
Age:
Gender:	Select Male Female
Date of Purchase
Serial number of NexDose® unit

All subsequent questions pertain to NexDose® user:
Number of medications you take every day (average):	Select 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 More than 15
Names of medications:

Name, address, phone of physician who provides most of your care
Name:
Street 1:
Street 2:
City:
State:	State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip:
Phone:

Name, address, phone of pharmacy where you get most of your medications:
Name:
Street 1:
Street 2:
City:
State:	State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip:
Phone:

Name, address, phone of hospital where you go for emergency care
Name:
Street 1:
Street 2:
City:
State:	State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip:
Phone:

Do you plan to program NexDose® yourself, or have someone else do it?	Select Me Someone else
If available, would you prefer your pharmacist or physician to program NexDose®?	Select No Yes, Either Yes, Pharmacist Yes, Physician
Medical insurance company name:
Please check all medical problems that you have (confidential):
Alzheimer's disease Arthritis Asthma Blood clots Cancer Chronic/recurrent infections Chronic pain Diabetes (insulin shots) Diabetes (oral medication only) Emphysema	Heart disease High blood pressure High cholesterol Psychiatric Seasonal Allergies Seizures/Epilepsy Stomach ulcer Stroke Transplant patient
Other: please list

Why do we want this information?

We will not discuss your individual medical information with third parties, including physicians, pharmacists, or hospitals. We may contact them regarding sales of NexDose® for their patients and NexDose® health care accessories for their patient care areas. We ask for the names of your medications and your medical problems to help us find patient populations that may benefit most from NexDose®.

	NexDose® may contact me regarding my satisfaction with the product
	I would like to be contacted by other companies related to NexDose®

Thank you for registering! If you were able to input your serial #, your warranty is now activated. If you don't yet have your NexDose®, please return to this page when you recieve it. You only need to fill in the fields in red, including your NexDose® serial number to activate your warranty. Thank you!