Topical A OTC Feedback Survey | Panag Pharma Inc.

Topical A^OTC Feedback Survey

Your feedback is important to us & will help our research team improve Topical A^OTC.

The survey consists of questions in relation to your experience with Topical A^OTC and takes no more than 5 minutes to complete. Upon successful completion of the survey we will send you a free bottle of Topical A^OTC.
Survey Password*
To begin the survey, please enter the password provided with your sample bottle of Topical A^OTC.
Download & Print The Feedback Survey

If you do not wish to take the online feedback survey, you can download the Topical A^OTC Feedback Survey & submit the completed survey to survey@panagrx.com.

Please Note

The Topical A^OTC feedback survey is currently limited to participants of the clinical trial and only one survey may be submitted per household. If you are having problems entering the survey or your password is not working, please contact us.

Step 1 - Personal Info
Step 1 of 10

Your Personal Information & Contact Details
Please provide your personal information & contact details.
Your Name*
First Last
Your Email*
Enter Email Confirm Email
Your Phone #*
Your Age*
Please enter a number from 18 to 99.
Your Sex*
- Male
- Female
Is it OK if we contact you for marketing purposes?*
- Yes
- No
Do you consent to sharing your Personal Information & Product Experience with Panag Pharma Inc.?*
- Yes
- No
All information collected by Panag Pharma Inc. will remain strictly confidential & held with regards to our privacy policy.
We're sorry, but in order to participate in the Topical A^OTC survey & receive your free bottle of Topical A^OTC, you must consent to sharing your Personal Information & Product Experience.
Please contact us for more information.

Step 2 - Address Info
Step 2 of 10

Your Address
Please provide your address information so we can send you your free bottle of Topical A^OTC.
Your Address Information*
Address Line 1 Address Line 2 City Province Postal Code

Step 3 - Product Use
Step 3 of 10

Product Use
On average, how often do you use Topical A on a daily basis? Please select the option that best describes your average daily use of Topical A^OTC:
Average Daily Use*
- 1 - 3 Times / Day
- 4 - 6 Times / Day
- More Than 6 Times / Day
Why Are You Using Topical A OTC?*

Step 5 - Treatment Satisfaction
Step 5 of 10

Treatment Satisfaction
How Satisfied Are You With Topical A^OTC? Please select a number that best describes your level of satisfaction:
Level Of Treatment Satisfaction*
- -3 - Very Unsatisfied
- -2
- -1
- 0 - Neither Satisified Nor Dissatisfied
- 1
- 2
- 3 - Completely Satisfied

Step 6 - Treatment Irritation
Step 6 of 10

Treatment Irritation
Did you experience any irritation at the site of application from Topical A^OTC?
Irritation?*
- Yes
- No
Please Describe The Irritation You Experienced*

Step 7 - Side Effects
Step 7 of 10

Side Effects
Did you experience any side effects from using Topical A^OTC?
Side Effects?*
- Yes
- No
Please Describe The Side Effects*

Step 8 - Product Applicator
Step 8 of 10

Product Applicator
Did you find the Topical A^OTC applicator convenient?
Was The Product Applicator Convenient & Easy To Use?*
- Yes
- No
Please Describe The Issue(s)*

Step 9 - Product Feel
Step 9 of 10

Product Characteristics
Was the Topical A^OTC appealing to use? E.g. It wasn't overly greasy or had an offensive scent.
Was The Product Appealing?*
- Yes
- No
Please Describe The Issue(s)*

Step 10 - Additional Feedback
Step 10 of 10

Additional Comments Or Feedback?
Please let us know if you have any additional comments or feedback during your experience with Topical A^OTC
Comments / Feedback
Name
This field is for validation purposes and should be left unchanged.

Topical A^OTC Feedback Survey

Download & Print The Feedback Survey

Please Note

Step 1 - Personal Info

Your Personal Information & Contact Details

Step 2 - Address Info

Your Address

Step 3 - Product Use

Product Use

Step 4 - Pain Relief

Pain Relief

Step 5 - Treatment Satisfaction

Treatment Satisfaction

Step 6 - Treatment Irritation

Treatment Irritation

Step 7 - Side Effects

Side Effects

Step 8 - Product Applicator

Product Applicator

Step 9 - Product Feel

Product Characteristics

Step 10 - Additional Feedback

Additional Comments Or Feedback?

Topical AOTC Feedback Survey

Download & Print The Feedback Survey

Please Note

Step 1 - Personal Info

Your Personal Information & Contact Details

Step 2 - Address Info

Your Address

Step 3 - Product Use

Product Use

Step 4 - Pain Relief

Pain Relief

Step 5 - Treatment Satisfaction

Treatment Satisfaction

Step 6 - Treatment Irritation

Treatment Irritation

Step 7 - Side Effects

Side Effects

Step 8 - Product Applicator

Product Applicator

Step 9 - Product Feel

Product Characteristics

Step 10 - Additional Feedback

Additional Comments Or Feedback?

Topical A^OTC Feedback Survey