Register Your TheraTogs Product Product Registration Please fill out the requested information below to the best of your abilities. We suggest you have the exterior packaging (typically a ziplock bag) *or* your order paperwork handy, as it has information you'll need to fill out the form. Customers who complete the Product Registration form will receive a free thank-you gift, as an expression of our appreciation for providing your information! Privacy and Consent*We will protect the privacy of any data you provide us. Your information will not be shared, and you’ll receive a confirmation email when you submit this form. You can review our full Privacy Policy here. I agree to the privacy policy.Your Relationship to TheraTogs Wearer* Wearer Parent / Caregiver PT OT CO / CPO Other Caregiver Name* First Last Caregiver Email* Caregiver Address*This is the address to which we will send our Product Registration thank-you gift! Street Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Therapist or Clinician's Name First Last Therapist or Clinician's Email Name of Clinic or PracticeProduct InformationThese optional questions pertain to the TheraTogs product you received.Registration Number*Please enter the unique Product Registration Number (PRN) that will be found on the outer packaging of your TheraTogs system. If you don't have a PRN, enter today's date in DDMMYYYY format, numbers only.Date You Received Your TheraTogs Date Format: MM slash DD slash YYYY TheraTogs Size & Model CodeEnter the size and model code found on your product package. Example: "GPTA210".Age of WearerEnter in months, or months + years. Examples: "6 mo" or "2 yrs + 3 mo".Primary Diagnosis or Indication*Enter the primary diagnosis or indication(s) which this TheraTogs system is intended to address. Quick SurveyAnswers here are optional, but much appreciated!Is this your first TheraTogs system?YesNoWhere/how did you first hear about TheraTogs?From therapist or clinicianFrom parent or caregiverBy searching the WebFrom website or blogFrom email or newsletterAt tradeshow, conference, or other meetingHow were your TheraTogs purchased?Out of pocket / cash payInsurance reimbursementMedicaid / MedicareEarly Intervention programWhat Billing Code was used(If you know, that would be very helpful... this is usually a code like L0456, L1499, or something similar.)If reimbursed, by which payor (Medicaid, government program, or insurance company?Who were your TheraTogs obtained from?Clinician / Clinic / Health care facilityO&P ProviderDME SupplierCatalog or DistributorTheraTogs SellerPlease enter the name of the organization from whom your TheraTogs were purchased, if known.CommentsThis field is for validation purposes and should be left unchanged.
