Physician Survey

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.

(*Required Fields)

Name Name First Last
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Phone
Email
Speciality
1. How did you hear about SINUS RINSE™?

1. How did you hear about SINUS RINSE™? Samples Flyer Brochure Patient Newspaper Television Radio Other
2. Have you recommended SINUS RINSE™ to your patients?

2. Have you recommended SINUS RINSE™ to your patients? Yes No
3. Will you consider recommending SINUS RINSE™ to your patients?

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?

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.)

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?

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

Physician Survey

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