What type of ostomy do you have?

How did you hear about PERMA-TYPE products?

Did you know that PERMA-TYPE has a registered nurse to assist you with any questions regarding our products?
Yes No

Are you satisfied with the customer service you receive?
Yes No

Are you satisfied with the quality and durability of PERMA-TYPE products?
Yes No

Have you used other ostomy products in the past?
Yes No
If yes, which one(s)?

How did they compare in quality and price to PERMA-TYPE products?

Are you tired of high cost disposable ostomy supplies?
Yes No

Do you frequently have problems with leakage and skin breakdown?
Yes No

How well does your appliance fit?
Excellent Good Fair Poor

Have you ever considered changing from what you are presently using?
Yes No

Are you satisfied with the length of time your appliance stays on?
Yes No

Is your Ostomy appliance easy to apply?
Yes No

Does your ostomy appliance interfere with your lifestyle?
Yes No

What is the average length of time you can wear your appliance, before you need to change?

If you have had problems with skin breakdown, what products have you used to heal and prevent further skin breakdown?

What manufacturer made your skin care products?

Who did you purchase your skin care needs from?

Do you have contact with an enterostomal therapist, and if so, what is his/her name and phone number?

May we ask your age?

Are you presently on Medicare?
Yes No

What is your current telephone number?

What is your email address?

What city, state and store do you currently buy your ostomy products from?

What other products(s) would you like PERMA-TYPE to carry?

Your comments are important to us. Please provide any other information below.