NeilMed Pharmaceuticals, Makers of Sinus Rinse, NasaFlo Netipot, Nasal Irrigation

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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)

First Name *	MI Last Name *
Address *
City *	State * ZIP *
Day Phone *	Email *
Specialty *

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

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

Yes

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

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

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

Yes

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.

Patent Numbers: USA-6,520,384 / 6,669,059 / 6,688,497 Canada-2,443,970 Australia-09/845,759
New Zealand-534041 Mexico-Pa/a/2003/009867. Other patents issued or pending internationally.

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