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CUSTOMER SURVEY

Customer Survey Form
To help us improve our products, please fill out this survey. In exchange for your time, WE WILL MAIL YOU A FREE NasaDock®.

All fields are mandatory
Please note: Use Mozilla Firefox or Internet Explorer on PC & Mozilla Firefox or Safari on MAC while filling up the survey for free NasaDock. 		neti pot, nasogel, nasamist, nasadock
Why should I fill out this survey
  • Free NasaDock®.
  • Notices about NEW products, sales and promotions.
  • Medical literature on nasal and sinus disease.
  • To help provide your doctor with samples and educational brochures that benefit all their patients.
Customer Information
First Name *   MI  Last *
Country *        County 
Address1 *
Address2
Town/City *     Postal Code* 
Phone     Email*
Did a physician recommend NeilMed® Sinus Rinse™ and/or NasaFlo® Neti Pot to you?
 Yes     No
If so, which do you use?
 Sinus Rinse™  NasaFlo® Neti Pot  Both
Physician Information ( If you do not have physician details, please enter NA)
Physician Name 
Address1
Address2
City   State/Province
Zip/Postal Code:   Phone:
Country 
1. Where did you purchase NeilMed's SinusRinse™ products?
 Physician  Pharmacy  Mail Order  Gift  Other
If Other, specify
2.  What was your previous method of nasal rinse?
 SinusRinse™ by NeilMed  Bulb Syringe
 Saline Spray  Saline solution in the palm and sniffing
 Electrical irrigation  None
3. How would you compare SINUS RINSE™ or NasaFlo® Neti Pot to others?
 Superior  Same  Inferior
4.  What is your overall rating of the SinusRinse™ or NasaFlo® Neti Pot?
 Excellent  Good  Satisfactory  Needs Improvement
Comments:
5.  Would you recommend NeilMed's SinusRinse™ or NasaFlo® Neti Pot?
 Yes  No
6. Did your condition improve by using SinusRinse™ or NasaFlo® Neti Pot?
 Significantly  Moderately  Mildly  No improvement
7a. How often do you use the SinusRinse™ or NasaFlo ® Neti Pot?
 Once a day  Twice a day  Every other day  As needed
7b. Do you use the SinusRinse™ or NasaFlo ® Neti Pot.....
 Seasonally  Throughout the Year
8. With NeilMed's SinusRinse™ or NasaFlo® Neti Pot, was there a change in...
  Not Applicable No Change Reduced Stopped Using
..use of antihistamines?
..use of corticosteroid nasal sprays?
..use of OTC nasal decongestants?
..frequency of antibiotic therapy?
..asthma related symptoms?
9. Did frequency of sinus infections or colds, reduce with the use of NeilMed's SinusRinse™ or NasaFlo® Neti Pot?
 Stopped Completely  Reduced  No Change
10. 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
11. Did you experience any immediate side effects with NeilMed's SinusRinse™ or NasaFlo® Neti Pot? (check all applicable)
 None  Headache  Earache
 Watery eyes  Congested nose  Nasal burning
12. What was the duration of any side effects?
 Minutes  Few hours  A day  Up to 3 days  A week
13. Did side effects prevent you from using NeilMed's SinusRinse ™ or NasaFlo® Neti Pot?
 Yes  No
14. Did the benefits outweigh the side effects of using NeilMed's SinusRinse™ or NasaFlo® Neti Pot?
 Yes  No
15.  Any additional Comments/Suggestions:
 
Thank you for filling out this survey.
Customer Information
First Name *   MI  Last *
Country *        County 
Address1 *
Address2
Town/City *     Postal Code* 
Phone     Email*
Did a physician recommend NeilMed® NasaMist® and/or NasoGel ® to you?
 Yes     No
If so, which do you use?
  NasaMist®  NasoGel®  Both
Physician Information ( If you do not have physician details, please enter NA)
Physician Name 
Address1
Address2
City   State/Province
Zip/Postal Code:   Phone:
Country 
1. Are you a NasaMist® or NasoGel® user?
 NasaMist®  NasoGel ®
2. Where did you purchase NeilMed NasaMist® or NasoGel® ?
 Physician  Pharmacy  Mail Order  Gift  Other
If Other, specify
3. What nasal gel product(s) have you used previously?
4. What nasal saline spray(s) have you used previously?
5. How would you compare your NeilMed product?
 Superior  Same  Inferior
6.  What is your overall rating of the NasaMist® or NasoGel®?
 Excellent  Good  Satisfactory  Needs Improvement
Comments/Suggestions
7.  Would you recommend NeilMed's NasaMist® or NasoGel®?
 Yes  No
8.Did your nasal dryness condition improve by using the NeilMed® NasaMist® or NasoGel®?
 Significantly  Moderately  Mildly  No improvement
9. How often do you use the NeilMed® NasaMist® Saline Spray or NasoGel®?
 Once a day  Twice a day  Every other day  As needed
10. After using NeilMed® NasaMist® Saline Spray or NasoGel®, was there a change in the use of other medications?
 Not Applicable  No Change  Reduced  Stopped Using
11. Are you using oxygen?
 Yes  No
12. Are you using CPAP for obstructive sleep apnea?
 Yes  No
13. What is the duration of benefit?
 1hr  2hr  3hr  4hr  5hr  6hr
14. Did the frequency of sinus infections or colds reduce with the use of NasaMist® Saline Spray or NasoGel® by keeping the nose moist?
 Stopped Completely  Reduced  No Change
15. 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
16. Did you experience any immediate side effects with NasaMist® Saline Spray or NasoGel®? (check all applicable)
 None  Headache  Earache
 Watery eyes  Congested nose  Nasal burning
17. What was the duration of any side effects?
 Minutes  Few hours  A day
18. Did side effects prevent you from using NeilMed NasaMist® or NasoGel®?
 Yes  No
19. Did the benefits outweigh the side effects of using NeilMed NasaMist® or NasoGel®?
 Yes  No
20.  Any additional Comments/Suggestions:
 
21. I will go to the store to purchase NeilMed® NasaMist® Saline Spray or NasoGel® products.
 Yes  No
Thank you for filling out this survey.
Survey must be 100% complete in order to receive your free NasaDock.
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