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Record of visit to

.........SHOWROOM

Sales Consultant: ............

Customer Name: ...................

Store Phone No. ............

Customer Phone No. ...........................

Date of Visit. ....../ /..

Suburb. ...............

The new bed must: .....................................................................................................................................................................


Wish List : ....................................................................................................................................................................................
: ....................................................................................................................................................................................
Name
.....

Name
waking up with lower back stiness and pain
experiencing numbness and tingling down arm
mis-alignment of upper shoulders and neck
high pressure on hips
snoring
tiredness due to heavy excercise or work, want to recuperate quicker

.....

BODY SHAPE MEASUREMENTS:


................ Shoulder - to - Waist ..................
dierence
................ Lumbar Curve depth .................
(approx)
When you lie on the mattress...

If the depression at waist = 2cm, then


For .................. The shoulder must depress: 2+ ........ = .......... and the Firmness Variation muct be greater than ............%
For .................. The

2+ ........ = ..........

............%
IF THIS IS NOT SO, ----- the Mattress will be much TOO FIRM at the shoulder - & NOT SUPPORTIVE enough at the waist.
Mattress/Ensemble chosen:
1.

Current List Price:

2.
Delivery Type:

Amount:

Reason for Visiting Beds for Backs? .............................................................................................................................................


Customer understands that all information and recommendations oered by Beds for Backs are provided in good faith and without guarantees as to their remedial
eectiveness and will not hold Beds for Backs responsible for it. Prices quoted above are valid for 10 days from date of visit.
Prices are subject to change prior to notification.
DV NOV09

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