Thank you for your interest in Little Remedies Products.
To process your request and to receive FREE samples that are currently available for your patients, we would greatly appreciate your completing this brief questionnaire. This information will help us to better understand your needs as well as those of your patients.
* Required Fields
*Name:
*Title:
MD
RN
LP
OTHER
*Practice Name:
* Office Address:
Suite:
*City:
*State:
Country: USA
*Zip:
* Office Phone:
* Office Fax:
* E-mail Address:
Sample Requested:
Little Noses Saline Spray/Drops
Little Noses Decongestant Nose Drops
Requests for samples will not be processed without correct professional address and office phone number for verification. Allow 4 to 6 weeks for delivery.
1.
How did you hear about Little Remedies Products?
Health Care Professional
Parent
Magazine
Other:
2.
Have you recommended any of our products to your patients before?
NO
YES; If yes, which product(s)? (check all that apply)
Little Noses Products
Saline Spray/Drops
Decongestant Nose Drops
Little Colds Products
Multi-Symptom
Decongestant + Cough
Soothing Throat Strips
Soothing Throat Pops
Little Remedies Kits
Stuffy Nose Kit
Poison Treatment Kit
Little Tummys Products
Gas Relief Drops
Laxative Drops
Other
Little Remedies Products
Little Teethers Gel
3.
Within the Little Remedies® Products line are there any products that you would like to see made available in sample sizes?
NO
YES, If yes, which product(s)
4.
Do you recommend OTC products for your patients under 6 years of age?
NO
YES; If yes, which type of product(s)? (check all that apply)
Cough/Cold
Nasal Preps
Laxatives
Gas
Teething
Vitamins
Analgesics
5.
How many Practitioners are currently in your practice?
6.
Approximately how many patients does your practice see weekly?
7.
Which professional magazine(s) do you read on a regular basis?
Contemporary Pediatrics
Journal of Pediatrics
Peds in Review
Infectious Diseases
Jama
Other
8.
Is there a pharmacy that you would like to see stock our products?
NO
YES; If yes, please complete the following:
Name:
Phone:
9.
Comments or suggestions?
