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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
Nasa
Dock
®
STAND,
NasaMist
®
or
Naso
Gel
®
product.
Why should i fill out this survey
Free Neil
Med
®
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 Neil
Med
®
Sinus Rinse
™
,
Nasa
Flo
®
Neti Pot,
NasaMist
®
and/or Naso
Gel
®
products to you?
Yes
No
If so, do you use
SinusRinse
™
,
Nasa
Flo
®
Neti Pot,
NasaMist
®
and/or
Naso
Gel
®
Sinus Rinse
Nasa
Flo
®
Neti Pot
NasaMist
®
Naso
Gel
®
Physician Information
Physician Name
City
State/Province
Zip/Postal Code:
Phone:
Neil
Med
®
SinusRinse
™
and
Nasa
Flo
®
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
Neil
Med
Bulb Syringe
Saline Spray
Saline solution in the palm and sniffing
Electrical irrigato
None
3. How would you compare
SINUS RINSE
or
Nasa
Flo
®
Neti Pot to others?
Superior
Same
Inferior
4. What is your overall rating of the
SinusRinse
™
or
Nasa
Flo
®
Neti Pot system?
Excellent
Good
Satisfactory
Needs Improvement
Comments:
5. Would you recommend
SinusRinse
™
or
Nasa
Flo
®
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
Nasa
Flo
®
Neti Pot system?
Once a day
Twice a day
Every other day
As needed
7b. Do you use the
SinusRinse
™
or
Nasa
Flo
®
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
Nasa
Flo
®
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
Neil
Med
'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
Neil
Med
's
SinusRinse
™
?
Yes
No
14. Did the benefits outweigh the side effects of using
Neil
Med
's
SinusRinse
™
?
Yes
No
15. Any additional Comments/Suggestions:
Neil
Med
®
NasaMist
®
and
Naso
Gel
®
users
1. Are you a
NasaMist
®
or
Naso
Gel
®
user?
NasaMist
®
Naso
Gel
®
2. Where did you purchase NeilMed products?
Physician
Pharmacy
Mail Order
Gift
Other
3. Which was your previous method of naso gel?
Neil
Med
®
Naso
Gel
®
Ayr Generic
Ocean
Simply Saline
®
4. Which was your previous method of nasal saline spray?
Neil
Med
®
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
Naso
Gel
®
?
Excellent
Good
Satisfactory
Needs Improvement
7. Would you recommend
NasaMist
®
or
Naso
Gel
®
?
Yes
No
8.Did your nasal dryness condition improve by using the NeilMed
®
NasaMist
®
or
Naso
Gel
®
?
Significantly
Moderately
Mildly
No improvement
9. How often do you use the NeilMed
®
NasaMist
®
Saline Spray or
Naso
Gel
®
?
Once a day
Twice a day
Every other day
As needed
10. After using NeilMed
®
NasaMist
®
Saline Spray or
Naso
Gel
®
,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
Naso
Gel
®
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
Naso
Gel
®
? (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
Neil
Med
products?
Yes
No
19. Did the benefits outweigh the side effects of using
Neil
Med
products?
Yes
No
20. Any additional Comments/Suggestions:
21. I will go to the store to purchase NeilMed
®
NasaMist
®
Saline Spray or
Naso
Gel
®
products.
Yes
No
17. I prefer that the following NeilMed
®
NasaMist
®
Saline Spray or
Naso
Gel
®
item sent to me free of charge.
NasaMist
®
Isotonic
NasaMist
®
Hypertonic
Naso
Gel
®
Spray
Naso
Gel
®
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.
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