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PRODUCT FEEDBACK

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First Name:
Last Name:
Address
City:
State:
Zip Code:
E-mail Address
Phone Number:
Are you? Male
Female
Are You? Under 35
36-45
46-55
56-65
66-75
75+
Your annual household income: Under $20,000
$20,001-$39,999
$40,000-$59,999
Over $60,000
1. What Knit-Rite brand did you purchase at this time? If feedback is for a compression product proceed to question #2. If feedback is for SmartKnit, SmartKnitKIDS, or Therasock products please skip to question #7. Therafirm
Ease
Core-Spun
TherafirmLight
Core-Sport
GOGO by Therafirm
Preggers by Therafirm
SmartKnit
SmartKnitKIDS
Therasock
2. Have you worn compression hosiery before? Yes
No
3. If yes, what brand?
4. Date of Purchase (MM/YY)
5. Which style did you purchase at this time? Knee
Thigh
Full/Pantyhose
6. What compression level? 10-15mmHg Light Support
15-20mmHg Mild Support
20-30mmHg Moderate Support
30-40mmHg Firm Support
7. Please provided the 11 digit LOT# that is located on the bottom label of the box.
8. Where did you purchase your Knit-Rite product? Medical Supply Shop
Drug Store
Catalog
Internet
Discount Store
Other
9. What caused you to purchase? (Check all that apply) Information at the point of purchase
Referral by a medical professional
Suggestion of a friend/acquaintance
Print advertisement
Information on package
Other
9a. If other, please specify:
10. How many pairs did you purchase? 1
2
3
4
5
Other

11. On a scale of 1 to 10 how would you rate the following:
Quality 1
2
3
4
5
6
7
8
9
10
Fit 1
2
3
4
5
6
7
8
9
10
Comfort 1
2
3
4
5
6
7
8
9
10
Price 1
2
3
4
5
6
7
8
9
10
Overall Satisfaction 1
2
3
4
5
6
7
8
9
10
12. Would you be willing to help us with future projects or in testing new products? Yes
No
13. Comments / Questions:
14. We occasionally send special promos or new product information to customers. Would you like to receive these special offers? Yes
No
15. Please provide your E-Mail Address if you would like to receive promos or new product information.
!