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complete the below survey to qualify for a free smartwatch 

* See promotion details for qualification guidelines and commitment requirements. 

PATIENT INFORMATION
Fields marked with an asterisk (*) are required
Patient Name *
Patient Name
Patient Birth Date *
Patient Birth Date
BioLert is designed for patients aged 8 and older.
Patient Phone Number *
Patient Phone Number
BioLert currently runs on an Android smartphone only. Therefore, this phone number should link to the patient's Android phone. Caregivers are NOT required to have an Android phone.
CAREGIVER INFORMATION
Please complete this section if the patient is aged 16 or younger; caregiver should be 17 or older
Caregiver Name
Caregiver Name
Caregiver Phone Number
Caregiver Phone Number
PATIENT SEIZURE PROFILE
When do your seizures typically occur? *
PATIENT LIFESTYLE
How would you rate your level of activity on an average day? *
For example: sports, dance, workouts, cycling, yoga, etc.
SHIPPING INFORMATION
Should you qualify for the smartwatch giveaway, let us know where to send it
Address *
Address
SHARE YOUR EXPERIENCE
Were you aware of BioLert before this promotion?
If yes, which one(s)?
Check all that apply.
If Other, please specify.
Please explain why or why not.
QUESTIONS?

Information provided within this survey is for use by BioLert Ltd. only. Data will not be shared with third parties.