ErecAid Warranty Online Registration

Indicate Model    Classic          Esteem Manual         Esteem Automatic

Name            

Address 1     

Address 2     

City                    State          Zip                 

Province/Country          Postal Code   

Telephone Number (xxx-xxx-xxxx)          Date of Birth (MM/YYYY)       

Place Purchased         Date Purchased (MM/DD/YYYY)     

Email Address      

Do you wish to receive future information from Timm Medical?  Yes        No     

Type Name for Electronic Signature           Date (MM/DD/YYYY)      

Prescribing Physician's Name    

Medical Specialty:   Urology         Family Medicine          Internal Medicine          Other      

Physician's Address     

City         State        Zip       

Province/Country          Postal Code      

Telephone Number  (xxx-xxx-xxxx)      

By completing the online Warranty Registration I acknowledge receipt of the ErecAid System and User Guide.  The User Guide includes the Notice of Privacy Practices disclosure.

REGISTER WITHIN 30 DAYS OF PURCHASE TO RECEIVE THE FOLLOWING BENEFITS

  • Product Warranty (1 Year for Classic model, 5 Years for Esteem models)
  • Refund Options
  • Toll-free technical assistance

Timm Medical Technologies, Inc.

540 Pennsylvania Ave.

Suite 200

Fort Washington, PA 19034

Toll Free:  1-800-438-8511

www.Timmmedical.com