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 |
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MI |
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Last Name * |
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Address * |
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City * |
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State * |
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ZIP * |
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Day Phone * |
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Email* |
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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) |
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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