Do you suffer or have you been
diagnosed with any of these conditions:
Acne
Allergies
& Sinus
Alzheimer's
Anxiety
Arthritis
Asthma
Back
Pain
Cancer
Depression
Dermatological
Diabetes type 1
Diabetes
type 2
Gastrointestinal
GERD
Hair Loss
Heartburn
Heart disease
High Cholesterol
Hypertension
Insomnia
Multiple Sclerosis
Obesity
OBGYN
Osteoarthritis
Osteoporosis
Pulmonary
Thyroid
Ulcer
How
often do you experience symptoms?
Are you currently on
medication for any of these conditions?
If so, how long?
Do you have a preferred
brand? If Yes, Please List:
Are you experiencing any side
effects?
Are you satisfied with the
medication you are using?
Does your insurance cover the
cost of the medication?
Are you interested in
receiving information / newsletter on new medication for
your condition?
Protecting your privacy
and being compliant with the HIPAA marketing guidelines is
important to us. Take 5 Solutions LLC is a consumer data
compilation and direct response marketing firm. All data
collected is self reported by the consumer through online
surveys. We do not have access to your medical records and
do not enhance or overlay your private information with your
medical information. The self reported data you submit to
us will be shared with advertisers and used for marketing
purposes, including by pharmaceutical companies and their
advertising agencies. Take 5 Solutions only rents the data
and never sells or transfers the data to third parties. At
any point, should you decide to opt-out of these and future
mailings, please check the boxes below. We respect your privacy and your name shall be removed from
our database within 72 hours of your request.
I would prefer not to receive online offers, product information,
specials, updates from third party advertisers
I would prefer not to receive postal offers, product information,specials,
updates from third party advertisers
Unless
I have checked any of the boxes above, Take 5 Solutions,
LLC will assume that I do not mind receiving online,
postal or SMS offers.
