Registration – Ulcer

Registration – March Ulcer Surveys

Register to participate in a study to be conducted in the last two weeks of March, 1996. If you have used a prescription ulcer drug to treat an ulcer (not acid reflux), and live in or near the following cities, please contact us to participate:

• Phoenix, Arizona
• Atlanta, Georgia
• Allentown, Pennsylvania
• Morristown, New Jersey
• Minneapolis, Minnesota
• Syracuse, New York

Please provide the following information below OR call us toll-free at 1-800-492-4516 (ask for Paula or Douglas) if you fit the above requirements:

•           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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