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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® STAND, NasaMist® or NasoGel® product.		 neti pot, nasogel, nasamist, nasadock
Why should i fill out this survey
  • Free NeilMed® product.
  • 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 benefi t all their patients.
(items with * are required)
Customer Information
First Name *   MI Last *
Address *
City *    State/Province*
ZIP/Postal Code*
Phone    Email*
Did a physician recommend NeilMed® Sinus Rinse™, NasaFlo® Neti Pot, NasaMist® and/or NasoGel ® products to you?
 Yes     No
If so, do you use SinusRinse™, Nasa Flo® Neti Pot, NasaMist® and/or NasoGel®
 Sinus Rinse™  NasaFlo® Neti Pot
  NasaMist®  NasoGel®
Physician Information
Physician Name 
City   State/Province
Zip/Postal Code:   Phone:
NeilMed® SinusRinse™ and NasaFlo ® Neti Pot users
1. Where did you purchase NeilMed's SinusRinse™ products?
 Physician  Pharmacy  Mail Order  Gift  Other
2.  Which was your previous method of nasal rinse?
SinusRinse™ by NeilMed  Bulb Syringe
 Saline Spray Saline solution in the palm and sniffing
Electrical irrigato 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 system?
 Excellent  Good  Satisfactory  Needs Improvement
Comments:
5.  Would you recommend SinusRinse™ or NasaFlo ® Neti Pot system?
 Yes  No
6. Did your condition improve by using SinusRinse™?
 Significantly  Moderately  Mildly  No improvement
7a. How often do you use the SinusRinse™ or NasaFlo ® Neti Pot system?
 Once a day  Twice a day  Every other day  As needed
7b. Do you use the SinusRinse™ or NasaFlo ® Neti Pot System.....
 Seasonally  Throughout the Year
8. With NeilMed's SinusRinse™ system, 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?
..use of Antibiotics?
..Asthma related symptoms?
9. Did frequency of sinus infections or colds, reduce with the use of SinusRinse™ or NasaFlo® Neti Pot System?
 No Change  Reduced  Stopped Completely
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™? (check all applicable)
 None  Headache  Earache
 Watering of 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 ™?
 Yes  No
14. Did the benefits outweigh the side effects of using NeilMed's SinusRinse™?
 Yes  No
15.  Any additional Comments/Suggestions:
 
NeilMed® NasaMist® and NasoGel ® users
1. Are you a NasaMist® or NasoGel® user?
 NasaMist®  NasoGel ®
2. Where did you purchase NeilMed products?
 Physician  Pharmacy  Mail Order  Gift  Other
3. Which was your previous method of naso gel?
NeilMed® NasoGel®  Ayr Generic
 Ocean Simply Saline®
4. Which was your previous method of nasal saline spray?
NeilMed® NasaMist®  Ayr Generic
 Ocean Simply Saline®
5. How would you compare your NeilMed product?
 Superior  Same  Not As Good
6.  What is your overall rating of the NasaMist® or NasoGel®?
 Excellent  Good  Satisfactory  Needs Improvement
7.  Would you recommend 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?
 No Change  Reduced  Stopped Using Others
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?
 No Change  Reduced  Stopped Completely
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
 Watering of eyes  Congested nose  Nasal burning
17. What was the duration of any side effects?
 Minutes  Few hours  A day  Up to 3 days
18. Did side effects prevent you from using NeilMed products?
 Yes  No
19. Did the benefits outweigh the side effects of using NeilMed products?
 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
17. I prefer that the following NeilMed® NasaMist® Saline Spray or NasoGel® item sent to me free of charge.
 NasaMist® Isotonic  NasaMist® Hypertonic
 NasoGel® Spray  NasoGel ® Tube
Thank you for filling out this survey.
Survey must be 100% complete in order to receive your free nasadock stand, nasamist or nasogel product. Only one item per survey.
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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.   		 Tolle Free USA & CANADA
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