SIGVARIS MEDICAL Customer Feedback Form: Web & Response Cards

1. Customer Feedback Form

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Thank you for sharing your opinion on your SIGVARIS garments. Your feedback is important to us and helps us create even better products! This form should take less than 5 minutes to complete. Please note that although we are unable to personally respond to the comments on these surveys, we do read each and every one.

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* 1. Do you give your consent for SIGVARIS to share your feedback within sales or marketing programs? Besides your name and/or job title, your personal information will not be disclosed [i.e. height, weight, contact information, 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.

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* 2. Please provide your contact information.

Name:

Company:

Address:

Address 2:

City/Town:

State:

ZIP/Postal Code:

Country:

Email Address:

Phone Number:

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* 3. Gender:

Female

Male

Do not wish to disclose

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* 4. Your age group:

20-30 yrs

31-40 yrs

41-50 yrs

51-60 yrs

61-70 yrs

71+ yrs

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* 5. Please enter your weight: [ex. 157 lbs.]

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* 6. Your Height: [ex. 5 feet, 5 inches]

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* 7. What is your Shoe Size?

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* 8. Which SIGVARIS MEDICAL products are you wearing?

230 Cotton

360 Cushioned Cotton

500 Natural Rubber

710 Allure

770 Truly Transparent

780 EverSheer

860 Select Comfort

500 Armsleeve

900 Armsleeve

Other

Comments (please specify)

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* 9. What is the compression level of your garment?

15-20mmHg

20-30 mmHg

30-40 mmHg

40-50 mmHg

50-60 mmHg

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* 10. Which style? (Mark all that apply)

Knee Hi

Thigh Hi

Pantyhose

Maternity

Armsleeve

Open Toe

Closed Toe

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* 11. Where did you buy these?

Internet dealer

Retail Store

Pharmacy

Other

(please specify)

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* 12. How long have you used graduated compression 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:

Very Good

Good

Just Right

Poor

Very Poor

Don't Know

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* 14. Attractiveness:

Very Attractive

Attractive

Okay

Unattractive

Very Unattractive

Don't Know

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* 15. Durability:

Very Durable

Somewhat Durable

Not Very Durable

Don't Know

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* 16. Comfort:

Very Comfortable

Comfortable

Fine

Uncomfortable

Don't Know

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* 1. Do you give your consent for SIGVARIS to share your feedback within sales or marketing programs? Besides your name and/or job title, your personal information will not be disclosed [i.e. height, weight, contact information, etc.]

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* 2. Please provide your contact information.

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* 3. Gender:

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* 4. Your age group:

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* 5. Please enter your weight: [ex. 157 lbs.]

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* 6. Your Height: [ex. 5 feet, 5 inches]

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* 7. What is your Shoe Size?

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* 8. Which SIGVARIS MEDICAL products are you wearing?

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* 9. What is the compression level of your garment?

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* 10. Which style? (Mark all that apply)

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* 11. Where did you buy these?

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* 12. How long have you used graduated compression products?

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* 13. Fit:

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* 14. Attractiveness:

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* 15. Durability:

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* 16. Comfort:

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* 17. Would you like to make any additional suggestions or comments?