Product Feedback

First Name:

Last Name:

Address

City:

State:

Zip Code:

E-mail Address

Phone Number:

Are you?

Male
Female

Are You?

Under 35
36-45
46-55
56-65
66-75
75+

Your annual household income:

Under $20,000
$20,001-$39,999
$40,000-$59,999
Over $60,000

1. What Thuasne brand did you purchase at this time? If feedback is for a compression product proceed to question #2. If feedback is for SmartKnit, SmartKnitKIDS, Knit-Rite products please skip to question #7.

Therafirm
Ease
Core-Spun
Core-Sport
Preggers by Therafirm
SmartKnit
SmartKnitKIDS
Knit-Rite

2. Have you worn compression hosiery before?

Yes
No

3. If yes, what brand?

4. Date of Purchase (MM/YY)

5. Which style did you purchase at this time?

Knee
Thigh
Full/Pantyhose

6. What compression level?

10-15mmHg Light Support
15-20mmHg Mild Support
20-30mmHg Moderate Support
30-40mmHg Firm Support

7. Please provided the 11 digit LOT# that is located on the bottom label of the box.

8. Where did you purchase your Thuasne product?

Medical Supply Shop
Drug Store
Catalog
Internet
Discount Store
Other

9. What caused you to purchase? (Check all that apply)

Information at the point of purchase
Referral by a medical professional
Suggestion of a friend/acquaintance
Print advertisement
Information on package
Other

9a. If other, please specify:

10. How many pairs did you purchase?

1
2
3
4
5
Other

11. On a scale of 1 to 10 how would you rate the following:

Quality

1
2
3
4
5
6
7
8
9
10

Fit

1
2
3
4
5
6
7
8
9
10

Comfort

1
2
3
4
5
6
7
8
9
10

Price

1
2
3
4
5
6
7
8
9
10

Overall Satisfaction

1
2
3
4
5
6
7
8
9
10

12. Would you be willing to help us with future projects or in testing new products?

Yes
No

13. Comments / Questions:

14. We occasionally send special promos or new product information to customers. Would you like to receive these special offers?

Yes
No

15. Please provide your E-Mail Address if you would like to receive promos or new product information.