Sample Request

Sample Request

 Physicians and Medical Professionals Survey Form

At Health Solutions Medical Products Corporation we have a continued commitment to develop our physician referral base and appreciate the support we receive from physicians and leading healthcare professionals within the US and internationally. 

Please take a moment to complete our healthcare professional survey and sample request form.

(*) required fields

 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 productsto your patients?

   Yes

   No


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

   Yes

   No


5. Would you like a sample of the SinuPulse Elite to evaluate? Note: This offer is limited to qualified physicians only and is discretionary. 

   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) 

 

Thank you for filling out this survey.

 

 

 
 

Please click on the "SUBMIT" button to send this survey on-line OR print, then mail and fax to:

Health Solutions Medical Products Corp.
Customer Relations 
P.O. Box 4278 
Culver City, CA 90231-4278 U.S.A. 
Tel. 800.305.4095 (Toll-free within the continental United States) 
Tel. 310.837.3191 (Outside the United States, Alaska, and Hawaii) 
Fax.323.654.2739 
E-mail: sales@sinupulse.com