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Nirmal Ayur Life Pvt Ltd. : Patient Feed Back Form

Name : Sex : Male   Female
Age : Occupation :
Address :
Tel No. : Mob. No. :
Merital Status : Date of Anniversary :
Nature of Complaint : Product use :
User of product : Self   Others if others / Relationship :
Number of days Treatment taken : Product Info obtained from which media :
Relief obtained : (kindly include relief in terms of percentage and also how fast was the effect of the medicine felt) :
Services used : Satisfaction quotient :
Testimonials :
Publicity : Yes   No Photograph : Yes   No

Please Note :
1. This form is a regular feedback form to be duly filled in by the customer. Valid only if Signed.
2. This form in no way will be used for media or publicity purpose against the wishes of the customer.
3. The form is a mandatory part of the data collection work of the company Nirmal Ayur Life Pvt.Ltd.
4. The above information provided will remain strictly confidential.