Home Phototherapy SurveyHome Phototherapy Survey

Which condition are you treating?

Which condition are you treating? Psoriasis

Vitiligo

Eczema

Atopic Dermatitis

Seasonal Affective Disorder (SAD)

Other (please specify)

Have you been seen by a doctor for this condition?

Have you been seen by a doctor for this condition? Yes

No

Not yet, but planning to in the future

Which treatments have you tried so far? (click all that apply)

Which treatments have you tried so far? (click all that apply) Phototherapy in the doctor's office

Home phototherapy

PUVA

Coal tar

Enbrel

Humira

Stelara

Remicade

Raptiva

Protopic

Lotions/Gels

Vitamins

Cosmetics

Other (please specify)

Rate these characteristics based on importance when choosing a treatment for this condition:

	Not Important	Somewhat Important	Very Important
Price/Cost	Rate these characteristics based on importance when choosing a treatment for this condition: Price/Cost Not Important	Price/Cost Somewhat Important	Price/Cost Very Important
Effectiveness	Effectiveness Not Important	Effectiveness Somewhat Important	Effectiveness Very Important
Safety	Safety Not Important	Safety Somewhat Important	Safety Very Important
Doctor's Opinion	Doctor's Opinion Not Important	Doctor's Opinion Somewhat Important	Doctor's Opinion Very Important
Rapid results	Rapid results Not Important	Rapid results Somewhat Important	Rapid results Very Important
Insurance Coverage	Insurance Coverage Not Important	Insurance Coverage Somewhat Important	Insurance Coverage Very Important
Convenience	Convenience Not Important	Convenience Somewhat Important	Convenience Very Important

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If you would like to receive home phototherapy information by mail, please fill out the information below, and we will be happy to send you a packet of product brochures and a complete price list for our home phototherapy products! Thank you! Name:
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