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iRelaxBot Referral Program Registration
First name
*
Last name
*
Email
*
Phone
*
Height ( inches)
Weight ( Lbs )
Age
*
Gender
*
Male
Female
Others
Multi-line address
País/región
*
Dirección
*
Dirección - Línea 2
*
Ciudad
*
Código postal
*
What's your role in related with iRelaxBot services
*
Business Owner
Service Operator - e.g. Store Manager, Technician or Massage Therapist who operate the iRelaxBot, etc.
User - non-insurance covered
Patient - insurance covered
What's your overall assessment to iRelaxBot based on your experience. please give a score here. ( 5 is the highest, and 1 is the lowest )
*
Which iRelaxBot product you have experienced
*
RTBP - Golden Silver
RTBF - Red
RTBF - Golden
RTBC - Gray
RTBH - White
Other
Title of Experience Description ( Please highlight which program is the most functions impressive to you. how iRelaxBot help you per your role described above.)
*
Description of Experience ( How you use it)
*
Benefits / Value of Service / What it help you
Add your text
File upload （ video record preferred）
*
Upload File
Your most fitting occupation for daily routine
*
Long hours Desk-Based Work >6 hours
Physically Demanding Work
On-Feet Active Work
Driving-intensive Work
Mixed Activity Work
High Physical Performance-based work
Retired
Student
Remote/Home Based Work
Your Interested Topics
*
Spine Health
Cardiovascular Health
Anti-Aging
Better Sleep
Diabetes
Weight & Shape Management
Other
When was the last time you did any physical exercise?
*
Yesterday
Last Week
2 weeks before
4 weeks before
How often do you usually engage in physical activity each month
*
>12
4 < X < 12
1< X < 4
< 1
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