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
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.