Thank you for your interest in our products. Please complete this short survey to request FREE samples of our electrodes and a chance to win a $100 Visa gift card.

First Name *
Last Name *
Title *
Company Name *
Email *
Phone Number *
Are you familiar with NMES (E-stim) for dysphagia?
Choose One Yes No
VitalStim Certified?
Yes No
• How often do you use NMES for dysphagia?
  Choose one Several times a week Several times a month About once a month Less than once a month Never
• What is most important to you regarding this product category?
  What is most important to you regarding this product category? Price Durability Quality Customer Service Convenience Friend's Recommendation Brand
• Which of the following brands do you purchase most often?
  Columbia Scientific VitalStim Guardian E-Swallow Alternative Electrodes Other
• How do you find out about new products and dysphagia news?
  Social Media (Twitter, Facebook, LinkeddIn, etc) Other Therapists Corporate Office/Administration Website Searches Email Other
• In a typical day, which following social networking websites do you use most often?
  Facebook LinkedIn Twitter Instagram You Tube Other
• In what setting do you work? *
  Choose an option below Outpatient Rehab Inpatient Rehab SNF Home Health Acute Care Private Practice None of the Above
• Request free samples of dysphagia electrodes
  Yes send me samples No (still in drawing for Visa gift card)

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