Support Therapy Feedback Form: Web & Response Cards
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1. Support Therapy Feedback Form
Thank you for sharing your opinion on your SIGVARIS garments, as your feedback helps us create better products for everyone! This form should take less than 5 minutes to complete.
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1
. Do you give your consent for SIGVARIS to share your feedback within sales or marketing programs? Besides your name, your personal information will not be disclosed [i.e. height, weight, etc.]
Do you give your consent for SIGVARIS to share your feedback within sales or marketing programs? Besides your name, your personal information will not be disclosed [i.e. height, weight, etc.]
Yes, I give my consent.
Yes, I give my consent, but do not share my name and/or job title.
No, I do not give my consent.
2
. Please provide your contact information.
Please provide your contact information.
Name:
Company:
Address:
Address 2:
City/Town:
State:
-- select state --
AL Alabama
AK Alaska
AS American Samoa
AZ Arizona
AR Arkansas
CA California
CO Colorado
CT Connecticut
DE Delaware
DC District of Columbia
FM Federated States of Micronesia
FL Florida
GA Georgia
GU Guam
HI Hawaii
ID Idaho
IL Illinois
IN Indiana
IA Iowa
KS Kansas
KY Kentucky
LA Louisiana
ME Maine
MH Marshall Islands
MD Maryland
MA Massachusetts
MI Michigan
MN Minnesota
MS Mississippi
MO Missouri
MT Montana
NE Nebraska
NV Nevada
NH New Hampshire
NJ New Jersey
NM New Mexico
NY New York
NC North Carolina
ND North Dakota
MP Northern Mariana Islands
OH Ohio
OK Oklahoma
OR Oregon
PW Palau
PA Pennsylvania
PR Puerto Rico
RI Rhode Island
SC South Carolina
SD South Dakota
TN Tennessee
TX Texas
UT Utah
VT Vermont
VI Virgin Islands
VA Virginia
WA Washington
WV West Virginia
WI Wisconsin
WY Wyoming
ZIP/Postal Code:
Country:
Email Address:
Phone Number:
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3
. Gender:
Gender:
Female
Male
Do not wish to disclose
4
. Your age group:
Your age group:
20-30 yrs
31-40 yrs
41-50 yrs
51-60 yrs
61-70 yrs
71+ yrs
5
. Race/Ethnicity:
Race/Ethnicity:
White/Caucasian
Asian
Black/African American
Hispanic/Latino
Native American
Pacific Islander
Do not wish to disclose
*
6
. Please enter your weight: [ex. 157 lbs.]
Please enter your weight: [ex. 157 lbs.]
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7
. Your Height: [ex. 5 feet, 5 inches]
Your Height: [ex. 5 feet, 5 inches]
8
. What is your Shoe Size?
4.5
5
5.5
6
6.5
7
7.5
8
8.5
9
9.5
10
10.5
11
11.5
12
12.5
13
13.5
14
14.5
15
15.5
16
What is your Shoe Size?
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9
. Which Support/Active Therapy products are you wearing?
Which Support/Active Therapy products are you wearing?
120 Sheer Fashion Hosiery - Knee Hi
120 Sheer Fashion Hosiery - Thigh Hi
120 Sheer Fashion Hosiery - Pantyhose
120 Sheer Fashion Hosiery - Maternity
146/186 Casual Cotton Socks
145/185 Classic Dress Socks
144/184 Athletic Recovery Sock
142/182 Cushioned Cotton Support Socks
180 Classic Ribbed Socks
10
. Where did you buy these?
Where did you buy these?
Internet dealer
Retail Store
Pharmacy
Other
(please specify)
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11
. What size was the product you wore?
What size was the product you wore?
A
B
C
D
E
F
Don't Know
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12
. How long have you used compression therapy products?
How long have you used compression therapy products?
Less than 1 year
1-3 years
3-5 years
5 years or more
Don't Know
Please tell us how you feel about this product by answering the questions below.
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13
. Fit:
Fit:
Very Good
Good
Just Right
Bad
Very Bad
Don't Know
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14
. Attractiveness:
Attractiveness:
Very Attractive
Attractive
Okay
Unattractive
Very Unattractive
Don't Know
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15
. Durability:
Durability:
Very Durable
Somewhat Durable
Not Very Durable
Don't Know
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16
. Comfort:
Comfort:
Very Comfortable
Comfortable
Fine
Uncomfortable
Don't Know
17
. Would you like to make any additional suggestions or comments?
Would you like to make any additional suggestions or comments?
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