ActivaPatch IontoGo 4.0

Name *

Company Name *

North Coast Medical Account #

Title *

Email *

Phone *

Who is your preferred distributor: *

North Coast MedicalPerformance HealthMedlineMeyerPTAdvantage MedicalPT UnitedOther

Which type of iontophoresis are you currently using? *

WiredWirelessNone

What is your preferred brand of wireless iontophoresis? *

ActivaPatch® IntelliDose™ 2.5ActivaPatch® IontoGo™ 4.0ActivaPatch® IontoGo™ 12.0IontoPatch STAT®IontoPatch® 80Other

Other distributor:

Other brand of wireless iontophoresis:

What is your preferred brand of wired iontophoresis? *

TrivarionNorcoOther

Are you satisfied with the quality and efficacy of your current iontophoresis? *

YesNoUnsure

Have you recently experienced any supply chain interruptions with your iontophoresis products? *

YesNo

Other wired iontophoresis

Mailing Address *

Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry

Samples are intended for healthcare professionals only.