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Physicians and Medical Professionals Survey Form

At Health Solutions Medical Products Corporation we are committed to continuous product improvement. Please help us achieve these efforts by taking a moment of your valuable time to complete this survey.

(Items marked with " * " are required)

First Name *

  MI Last Name *

Address *

 

City *

   State *    ZIP *

Day Phone *

   Email

Specialty *

 

1.  Please tell us how did you hear about our  irrigation product(s)?

  Sample

  Flyer

  Brochure

  Patient

  Newspaper

 Television

  Radio

  Other

2.  Have you recommended our irrigation products to your patients?

  Yes

  No

3.  Will you consider recommending our irrigation products to your patients?

  Yes

  No

4.  Do you think that our irrigation products will help your patient's achieve a better cure rate or freedom from symptoms?

  Yes

  No

5.  In your opinion, is our product information and instructions sufficient for your office staff and you? 

  Yes

  No

6.  Would you like  to stock our product(s), at a wholesale rate, to distribute to your patients?

  Yes

  No

7.  If no to question six, Please provide us with the name of your neighborhood pharmacy?


Independently  Owned Pharmacy (i.e. Smith Pharmacy)


Chain Drug Pharmacy (i.e. Walgreens)

8.  Do you have any suggestions for improving our product(s), marketing, or customer service?


Thank you for filling out this survey

Please click on the "SUBMIT" button to send this survey on-line OR print then mail or fax to:
 Health Solutions Medical Products Corporation
P.O. Box 4278
Culver City, CA 902131-4278
Tel. 899.305.4095 (within the US)
Tel. 310.837.3191 (Outside the US)
Fax: 310.837.1065
E-Mail: sales@pharmacy-solutions.com