Thank you for your interest in the Tango® Belt!

The Tango Belt is a prescription medical device, requiring a prescription from a physician. Product availability currently depends on your state of residence, as we're working to expand availability nationwide. Your answers will only be used internally to help us serve your request.

Please note, any information submitted in this survey will not be protected by HIPAA.

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* 1. How did you learn about the Tango Belt?

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* 2. Contact Information:

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* 3. What is the state of residence of the prospective Tango Belt wearer?

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* 4. Are you interested in the Tango Belt for yourself, or someone else?

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* 5. What is the age of the prospective Tango Belt wearer?

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* 6. Does the individual have access to WiFi?

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* 7. Does the individual have access to a smart phone or tablet?

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* 8. Home Setting: Where does the prospective Tango Belt wearer live?

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* 9. If Senior Living Community is selected, what is the name of the Senior Living Community?

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* 10. Does the prospective Tango Belt wearer have assistance for use of technology when needed?

The Tango Belt is priced at $8,400 (net purchase price). The Tango Belt can be purchased in full, or billed in twelve $700 installments over 12 months.

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* 11. Would you like someone to reach out to you about the potential purchase of a Tango Belt?

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