Name:

Email Address:

Have you ever been into a MyComfort Store before?

Yes
No

Which of the following effect you while you sleep?

Lower Back
Upper Back
Hips
Shoulders
Legs or Arms
Numbness
Apnea
Reflux
Other
None of the Above

Address

City/State/Zip Code

Phone Number

Would you rather setup a special appointment with a non-commissioned Sleep Consultant or just drop by the store on your own time?

Non-Commissioned Sleep Consultant.
I'd rather Drop by the store.

How many beds have you bought in the past ten years?

None 1 2 3 4 5+

Explain as best you can your biggest concerns about finding the right mattress, getting the right therapy, or your problems with purchasing beds in the past.

How important is it to you to be one of the first 50 customers to get the extra discounts?

It is extremely important.
It would be nice, but not necessary.
It doesn't influence my timing.