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Topical A OTC
Topical A OTC Feedback Survey
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Topical
A
OTC
Feedback Survey
Your feedback is important to us & will help our research team improve
Topical
A
OTC
.
The survey consists of questions in relation to your experience with
Topical
A
OTC
and takes no more than 5 minutes to complete. Upon successful completion of the survey we will send you a
free bottle
of
Topical
A
OTC
.
Survey Password
*
To begin the survey, please enter the password provided with your sample bottle of
Topical
A
OTC
.
Download & Print The Feedback Survey
If you do not wish to take the online feedback survey, you can
download the
Topical
A
OTC
Feedback Survey
& submit the completed survey to
[email protected]
.
Please Note
The
Topical
A
OTC
feedback survey is currently limited to participants of the clinical trial and
only one survey may be submitted per household
. If you are having problems entering the survey or your password is not working, please
contact us
.
Step 1 - Personal Info
Step 1 of 10
Your Personal Information & Contact Details
Please provide your personal information & contact details.
Your Name
*
First
Last
Your Email
*
Enter Email
Confirm Email
Your Phone #
*
Your Age
*
Please enter a number from
18
to
99
.
Your Sex
*
Male
Female
Is it OK if we contact you for marketing purposes?
*
Yes
No
Do you consent to sharing your Personal Information & Product Experience with Panag Pharma Inc.?
*
Yes
No
All information collected by Panag Pharma Inc. will remain strictly confidential & held with regards to our
privacy policy
.
We're sorry, but in order to participate in the
Topical
A
OTC
survey & receive your free bottle of
Topical
A
OTC
, you must consent to sharing your Personal Information & Product Experience.
Please
contact us
for more information.
Step 2 - Address Info
Step 2 of 10
Your Address
Please provide your address information so we can send you your free bottle of
Topical
A
OTC
.
Your Address Information
*
Address Line 1
Address Line 2
City
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland & Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Province
Postal Code
Step 3 - Product Use
Step 3 of 10
Product Use
On average, how often do you use
Topical
A
on a daily basis? Please select the option that best describes your average daily use of
Topical
A
OTC
:
Average Daily Use
*
1 - 3 Times / Day
4 - 6 Times / Day
More Than 6 Times / Day
Why Are You Using Topical A OTC?
*
Step 4 - Pain Relief
Step 4 of 10
Pain Relief
How well does
Topical
A
OTC
relieve your pain? Please rate the level of pain relief provided by using
Topical
A
OTC
by indicating the number that best describes your pain relief:
Level Of Pain Relief
*
0 - No Relief
1
2
3
4
5 - Moderate Relief
6
7
8
9
10 - Complete Relief
Step 5 - Treatment Satisfaction
Step 5 of 10
Treatment Satisfaction
How Satisfied Are You With
Topical
A
OTC
? Please select a number that best describes your level of satisfaction:
Level Of Treatment Satisfaction
*
-3 - Very Unsatisfied
-2
-1
0 - Neither Satisified Nor Dissatisfied
1
2
3 - Completely Satisfied
Step 6 - Treatment Irritation
Step 6 of 10
Treatment Irritation
Did you experience any irritation at the site of application from
Topical
A
OTC
?
Irritation?
*
Yes
No
Please Describe The Irritation You Experienced
*
Step 7 - Side Effects
Step 7 of 10
Side Effects
Did you experience any side effects from using
Topical
A
OTC
?
Side Effects?
*
Yes
No
Please Describe The Side Effects
*
Step 8 - Product Applicator
Step 8 of 10
Product Applicator
Did you find the
Topical
A
OTC
applicator convenient?
Was The Product Applicator Convenient & Easy To Use?
*
Yes
No
Please Describe The Issue(s)
*
Step 9 - Product Feel
Step 9 of 10
Product Characteristics
Was the
Topical
A
OTC
appealing to use? E.g. It wasn't overly greasy or had an offensive scent.
Was The Product Appealing?
*
Yes
No
Please Describe The Issue(s)
*
Step 10 - Additional Feedback
Step 10 of 10
Additional Comments Or Feedback?
Please let us know if you have any additional comments or feedback during your experience with
Topical
A
OTC
Comments / Feedback
Email
This field is for validation purposes and should be left unchanged.
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