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Gift to all CF patients from NeilMed
GIFT of NeilMed Sinus Rinse or NetiPot, each with 50 packets for nasal wash to all CF patients......... Products were developed by Ketan C. Mehta, MD, a pulmonary medicine specialist and founder of NeilMed Pharmaceuticals. Both items are # 1 physician recommended and # 1 selling products in the USA and Canada when it comes to Squeeze bottle or NetiPot systems for nasal irrigation.
Fill out below information and we will mail you FREE NeilMed Sinus Rinse™ kit or NeilMed NasaFlo Neti Pot
This offer is valid only if you become a NeilMed Sinus Rinse fan on Facebook and complete the survey. Repeat and duplicate entries will be discarded.
Only one item per sku per household
Why should I fill out this survey
  • To receive information on NEW products, sales & promotions and receive 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 other patient's benefit
I confirm that I have cystic fibrosis or immotile ciliary syndrome, or that I am filling out this paperwork on behalf of my parents or child or spouse. I understand that my personal information will be kept confidential at NeilMed and will not be given to any other company for marketing purposes. However, I also understand that NeilMed may send complimentary samples to my doctors for the benefit of other patients.
Customer Information
First Name *   MI Last *
Address1 *
Address2
City/Town *
ZIP/Postal Code*
Country *            State/Province * 
Phone*    Email*
Are you a registered NeilMed customer?
 Yes     No
Did a physician recommend NeilMed® Sinus Rinse™ or NasaFlo® Neti Pot to you?
 Yes     No
If so, which do you use? (check all that apply)
 NeilMed Sinus Rinse™  NeilMed NasaFlo® Neti Pot
Physician Information
Physician Name 
Address1
Address2
City   State/Province
Zip/Postal Code:   Phone:
Country 
 Which product you want to be shipped FREE to you?
 NeilMed Sinus Rinse™  NeilMed Neti Pot
1.  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
2. How would you compare SINUS RINSE™ or NasaFlo® Neti Pot to others?
 Superior  Same  Inferior
3.  What is your overall rating of the SinusRinse™ or NasaFlo® Neti Pot?
 Excellent  Good  Satisfactory  Needs Improvement
Comments:
4.  Would you recommend NeilMed's SinusRinse™ or NasaFlo® Neti Pot?
 Yes  No
5. Did your condition improve by using SinusRinse™ or NasaFlo® Neti Pot?
 Significantly  Moderately  Mildly  No improvement            N/A
6a. How often do you use the SinusRinse™ or NasaFlo ® Neti Pot?
 Once a day  Twice a day  Every other day  As needed                    N/A
6b. Do you use the SinusRinse™ or NasaFlo ® Neti Pot.....
 Seasonally  Throughout the Year                    Not Applicable
7. 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?
8. Did frequency of sinus infections or colds, reduce with the use of NeilMed's SinusRinse™ or NasaFlo® Neti Pot?
 Stopped Completely  Reduced  No Change
9. 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
10. 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
11. What was the duration of any side effects?
 Minutes  Few hours  A day  Up to 3 days  A week
12. Did side effects prevent you from using NeilMed's SinusRinse ™ or NasaFlo® Neti Pot?
 Yes  No
13. Did the benefits outweigh the side effects of using NeilMed's SinusRinse™ or NasaFlo® Neti Pot?
 Yes  No
14.  Any additional Comments/Suggestions:
   
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