Please complete this brief on-line survey for the chance to WIN* a year’s supply of COLD-FX.
See Rules & Regulations for details. 		 
   
Your Contact Information
First Name:
Last Name:
Address:
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Province:
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Your personal information will not be shared with any other marketers and will only be used by Afexa Life Sciences Inc. for the purposes you have consented to and in accordance with privacy laws and our privacy policy.

Yes, please include me on the mailing list for future COLD-FX information and promotions.
Yes, please include me on the mailing list for information about other products manufactured by Afexa Life Sciences Inc.		  
   

1. Have you ever used COLD-fX before?

Yes
  Which of the following statements best describes how you use COLD-FX?
   
No
  Please select the most accurate statement.

2. What is your gender?

3. What age group do you fall under?

4. How did you hear about COLD-FX? (Please check all that apply)
Friend, family member or work colleague
Pharmacist or doctor
Story in the news mentioning COLD-FX
Search engine results (Google, Yahoo, MSN, etc.)
TV advertisement
Radio advertisement
Newspaper advertisement
Magazine advertisement
Outdoor billboards
Online Ads
Subway/Transit Ads Signage at a Sports Game

 
 
   
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TM/® owned by Afexa Life Sciences Inc. unless otherwise marked
*Pharmacy Post Annual Survey on OTC Counseling & Recommendations, 2008.
**The Medical Post Annual Survey on OTC Counseling and Recommendations, 2008.