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

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NasoGel Survey Offer
We request that you fill out an important survey for product evaluation and on-going improvement. Your survey is very important to us and we value you as an important customer. Any input you give us will help improve our NasoGel^®. Our goal is to make the best possible NasoGel^® that gives the longest lasting moisture, without any side effects.

(items with * are required)

Customer Information

First Name *

MI Last *

Address *

City *

State/Province*

ZIP/Postal Code*

Phone

Email*

1. If a physician recommended NasoGel^® to you please provide their information.
Physician Name	Specialty
Address1
Address2
City	State
Tel #:

2. Where did you purchase NeilMed NasoGel^® products?
	Physician		Pharmacy		Mail Order		Other

3. Which was your previous method of nasal gel?
NasoGel^® by NeilMed Pharmaceuticals
Ayr Gel^®
Rhinaris^®
Ponaris^®
Nose Better

4. How would you compare NasoGel^® to others?
Superior	Same	Not As Good

5. What is your overall rating of NeilMed NasoGel^® to others?
Excellent	Good	Satisfactory	Needs Improvement
Comments for improvement:

6. Would you recommend NeilMed NasoGel^®?
Yes	No

7. Did your nasal dryness condition improve by using NeilMed NasoGel^®?
Significantly	Moderately	Mildly	No improvement

8. How often do you use NeilMed NasoGel^®?
Once a day	Twice a day	Every other day	As needed

9. With NeilMed NasoGel^®, was there a change in the use of other medications?
Not Applicable	No Change	Reduced	Stopped Using other medications

10. Are you using oxygen?
Yes	No

11. Are you using CPAP for obstructive sleep apnea?
Yes	No

12.What is the duration of benefit?
1hr 2hr 3hr 4hr 5hr 6hr

13. Did the frequency of sinus infections or colds reduce with the use of NasoGel^® by keeping the nose moist?
No Change	Reduced	Stopped Completely

14. 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

15. Did you experience any immediate side effects with NeilMed NasoGel^®? (check all applicable)
None	Headache	Earache
Watering of eyes	Congested nose	Nasal burning

16. What was the duration of any side effects?
Minutes	Few hours	A day	Up to 3 days	A week

17. Did side effects prevent you from using NeilMed NasoGel^®?
Yes	No

18. Did the benefits outweigh the side effects of using NeilMed NasoGel^®?
Yes	No

19. Any additional Comments/Suggestions:

20. I will go to the store to purchase the NasoGel^® products.
Yes	No
21. I prefer that the following NasoGel^® item is sent to me free of charge.
NasoGel^® Spray	NasoGel^® Tube
22. I do not prefer to use NeilMed NasoGel^® for the stated reason in the comments section. Please mail me a check for US $5.00 or CAD $5.00
Yes	No

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.