Physicians, Pharmacists and Medical Professionals Survey Form

We are committed to an ongoing product improvement effort. Please help us achieve it by taking a couple of minutes of your valuable time to fill this survey.

(Items With " * " Are Required)

1.  How did you hear about SINUS RINSE™?

Sample	Flyer	Brochure	Patient
Newspaper	Television	Radio	Other

2.  Have you recommended SINUS RINSE™ to your patients?

Yes

No

3.  Will you consider recommending SINUS RINSE™ to your patients?

Yes

No

4.  Do you think that our product design will improve your patient's compliance, hence, achieving a better cure rate or freedom from symptoms?

Yes

No

5.  In your opinion, is our instruction thorough enough to save time for your office staff and you? (Please review the different sections of FAQ's before answering this question.)

Yes

No

6.  Are you willing to stock this product, at a wholesale rate, to distribute to your patients?

Yes

No

7.  If no to question six, will you provide us with the name of your neighborhood pharmacy?

Privately Owned Pharmacy (for example, Jones Pharmacy)

Chain Pharmacy Store (for example, Walgreens)

8.  Do you have any suggestions for improving our rinse system, mixture packets, or brochure?

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, 1221 Farmers Lane, Suite 500, Santa Rosa, CA  95405
TEL:  707-525-3784  |  FAX:  707-525-3785  |  TOLL FREE:  877-477-8633