Registration – Genital Herpes

Registration – Genital Herpes

Register to participate in 1996 DMD Genital Herpes patient surveys.

•           Name:        Address 1:        Address 2:             City:            State:         Zip code:     Phone Number:  (optional)  E-mail address:           Diagnosis:           Current Medications:        Past Medications:       Your Pharmacy:              City:            State:   

  
  

Based on the information above, we may or may not contact you to participate in this survey. Participation is dependent upon specific required demographics and usage history. We will contact you periodically to maintain your prescription product use file for future surveys.

We appreciate your input and concern regarding products used to treat this condition. If you are interested in participating in other patient surveys, please fill out the Registration form to receive a DMD Patient Panel Enrollment Packet.

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