Pill Pal Splitter

Name *

Title *

Company Name *

Email *

Phone *

North Coast Account # *

1. Do you currently dispense pill splitters? *

YesNo

2. How many pill splitters do you dispense monthly? *

0 - 56 -1011 or more

3. Who is your preferred vendor for pill splitters? *

Performance HealthMedlineAliMed®Other

4. How much do you currently pay for pill splitters? *

$3 - $4$5 - $6$7 or more

5. If the Pill Pal Splitter is similarly priced, and performs better, would you be willing to switch to the Pill Pal Splitter? *

YesNo

Other Distributor:

Mailing Address

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

Samples are intended for healthcare professionals only.