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Please tell us about yourself so that we may better serve you.

 

 

First  Name:    
Last  Name:
State:
Email Address:   		 

 
Sex:     Male Female

Please check your age group:
 

Under 18
18 - 30
31 - 49
50 - 65
66 - above
 

Do you suffer from any of the following? (Please select all options that apply.)

Bunions         Corns           Heel Spurs      Flat Feet

Gout            Fallen Arches   Surgical Scars  Other
 

Would you like more information about foot therapy?

Yes No

Please check all of the products that you have previously tried.

Raspberry Delight    Banana Split         Chocolate Macadamia  Oatmeal Scrub      

Chamomile            Lemon Meringue       Menthol with Aloe    Summer Breezes     

Sassy Soother

We would like to know how you feel about our products. Please select one of the following:

 

We want to continue bringing you the best solutions for your feet.
Please send us your comments about products you would be interested in.

 

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Prepared by Estee Eubanks, Oklahoma State University.
Copyright © 2003. All rights reserved.
Revised: 06/11/09

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