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

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Customer Survey Form In our efforts to improve our product, we would appreciate, if you could fill out this survey. For filling out this survey WE WILL MAIL YOU FREE, A NasaDock^® STAND ($7.49 Value including Free Shipping)
Why should i fill out this survey
To recieve information on NEW products, sales and promotions and recieve medical literature on nasal and sinus disease. By providing the doctors name who suggested the product, we can provide the doctor with samples and educational brochures for the patients benefits.

(items with * are required)

Customer Information

First Name *

MI Last *

Address

City *

State/Province*

ZIP/Postal Code*

Phone

Email*

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 using SINUS 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/Suggestions:

Thank you for filling out this survey.
Survey must be complete in order to recieve the free NasaDock^® Stand

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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