Healthcare Professional Contact Form

Private-Door is an assisted living device that provides independence to users of wheelchairs, scooters and walkers. Private-Door also provides them a simple means to open their doors to visiting family and healthcare workers. Private-Door works closely with Federal, State, County and private agencies to provide the most dependable and economical product to the physically challenged. Please fill out the form below, and we will provide you with information on how Private-Door "will open doors of opportunity for your clients."
First Name		Middle Initial
Last Name
Organization
Street Address
City
State/Province		Zip Code
Country
Home Phone		Work Phone
FAX
E-mail		URL
	Please send a digital catalogue with Digital Demo Video.		Please send me a VHS Demo Video.
	Please send me the "Independent Living Program"
	I am interested in the following model:		I saw Private-Door in a magazine, web page or other.
	Please select one. No specific model Send information on all models. Private-Door Solo Private-Door Assistant Private-Door Duo Private-Door System Private-Door Remote Release
	Select a profession that best describes yours		I make
	Please select one. Independent Living Prof Therapist Consultant Architect Center for Independent Living Home Health Care Professional Assistive Living Professional State Agency Federal Agency Other		Please select one. Recommendations Purchases
	My need is		Contact Me
	Please select one. For future reference. Immediate 60 to 90 days 90 plus days		Please call.
			Send material only
Comments: Enter in any questions or comments that you may have regarding Private-Door or any product that is on the web site. If you found the Private-Door web site helpful click on the "Tell A Friend" link at the top of the page to email a friend about Private-Door. Private-Door does not log or store information sent from this link.

rc 5/7/04