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.