NeilMed Products - Sinus Rinse, Nasal Rinse, Sinusitis, Rhinitis, Allergies

		U.S. Patent Nos. 6,520,384 / 6,669,059 / 6,688,497	Selección de idioma

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DERECHO DE AUTOR
2000 - 2005
NEILMED PHARMACEUTICALS

Customer Survey Form In our efforts to improve our product, we would appreciate, if you could fill out this survey. Please mail survey with your next order or use our website and take $1.00 off. (Items With " * " Are Required)
Customer Information
First Name *	MI Last *
Address
City *	State* ZIP*
Day Phone	Email*
Evening Phone

1. If a physician recommended SINUS RINSE™ to you please provide their information.
Physician Name
City	State
Tel #:

2. Where did you purchase NeilMed's SINUS RINSE™ products?
	Physician		Pharmacy		Mail Order		Other

3. Which was your previous method of nasal rinse?
SINUS RINSE™ by NeilMed Products
Bulb Syringe
Saline Spray
Saline solution with electrical irrigator
Saline solution in palm and sniffing

4. How would you compare SINUS RINSE™ to others?
Superior	Same	Inferior

5. What is your overall rating of NeilMed's SINUS RINSE™ system?
Excellent	Good	Satisfactory	Needs Improvement
Comments:

6. Would you recommend NeilMed's SINUS RINSE™ system?
Yes	No

7. Did your condition improve by usingSINUS RINSE™?
Significantly	Moderately	Mildly	No improvement

8. How often do you use the SINUS RINSE™ system?
Once a day	Twice a day	Every other day	As needed

9. With NeilMed's SINUS RINSE™ system, was there a change in...
...use of Antihistamines?
Not Applicable	No Change	Reduced	Stopped Using
...use of Corticosteroid Nasal Sprays?
Not Applicable	No Change	Reduced	Stopped Using
...use of OTC Nasal Decongestants?
Not Applicable	No Change	Reduced	Stopped Using
...use of Antibiotics?
Not Applicable	No Change	Reduced	Stopped Using
...Asthma related symptoms?
Not Applicable	No Change	Reduced	Stopped Using

10. Did frequency of sinus infections or colds, reduce with the use of SINUS RINSE™?
No Change	Reduced	Stopped Completely

11. How do you feel about the price of our product compared to other systems on the market?
Priced too low	Reasonably priced	Priced too high

12. Did you experience any immediate side effects with NeilMed's SINUS RINSE™? (check all applicable)
None	Headache	Earache
Watering of eyes	Congested nose	Nasal burning

13. What was the duration of any side effects?
Minutes	Few hours	A day	Up to 3 days	A week

14. Did side effects prevent you from using NeilMed's SINUS RINSE™?
Yes	No

15. Did the benefits outweigh the side effects of using NeilMed's SINUS RINSE™?
Yes	No

16. Any additional Comments:

Thank you for filling out this survey.

Please click on the "SUBMIT" button to send this survey on-line OR print then mail or fax to:
NeilMed Products, Inc., 1221 Farmers Lane, Suite 500, Santa Rosa, CA 95405
TEL: 707-525-3784 | FAX: 707-525-3785 | TOLL FREE: 877-477-8633, 866-SINUSRX