Please enable JavaScript in your browser to complete this form. - Step 1 of 6Thank You Thank you for taking this brief survey. The survey consists of about 10 questions and should take less than 5 minutes to complete. Unless you submit your name or email, no personal information will be stored or used. Survey completion and a valid email address are required to be eligible for the Amazon gift card drawing. Your response is greatly appreciated and will help DisposeRx advance our mission to end medication misuse. NextAbout DisposeRx Below are a few questions about DisposeRx packets and our value add services. Please answer the questions below to the best of your knowledge. How did you first hear of DisposeRx?Web SearchWord of Mouth ReferralConference or EventLocal Community Non-profit / ProgramOtherOtherIf you selected other, please share:Are you aware DisposeRx also offers bulk medication disposal products for use in your office or facility?YesNoAre you aware of the DisposeRx case studies supporting the use of in-home medication disposal?YesNoWould you like a copy of these sent to you electronically?YesNoEmailYour email address will only be used to send the case studies.Do you use the DisposeRx educational/support materials?YesNoDid you know that DisposeRx provides educational/support materials in multiple languages?YesNoPreviousNextProduct Interaction Below are a few questions about DisposeRx packets and how you may or may not use them. Please answer the questions below to the best of your knowledge. Are you using DisposeRx as part of a medication disposal program?YesNoHow are you using the product today?Included with every prescriptionIncluded with most prescriptionsIncluded only with opioidsBy requestOtherOtherIf you selected other, please share:Why do you provide DisposeRx?Patient engagementCommunity outreachRisk mitigationEnvironmental concernOtherOtherIf you selected other, please share:Do you charge for DisposeRx packets? Provided free$1-$2$2-$3$3-$4$5+ Please selectProvided freePlease select Provided free$1-$2Please select $1-$2$2-$3Please select $2-$3$3-$4Please select $3-$4$5+Please select $5+ Now or in the past, have you billed DisposeRx packets to a(n) insurance company?YesNoBilling CodeWhat billing code did you use for the packet? (ex./ 99070)If DisposeRx, Inc. offered a free subscription plan, would you subscribe? How often would you like shipments? MonthlyEvery 2 monthsEvery 6 monthsYearlyI would not subscribe Please selectMonthlyPlease select MonthlyEvery 2 monthsPlease select Every 2 monthsEvery 6 monthsPlease select Every 6 monthsYearlyPlease select YearlyI would not subscribePlease select I would not subscribe PreviousNextAbout You Below are a few questions about you. Please answer the questions below to the best of your knowledge. How would you best describe your business type?Hospital/Health SystemLong Term Care/Hospice FacilityHome Health ProviderPrivate PracticeHealth PlanOtherWhat type of private practice:PainNeuropathyOrthopedicOral SurgeryOtherOtherIf you selected other, please share:Where do you think we can connect with more practices, businesses, or organizations like yours to adopt our product?Would you be willing to provide a testimonial?YesNoName *FirstLastEmail *PreviousNextContest information If you wish to be entered into the gift card drawing please enter your first and last name, organization name and email address below. Gift card will be delivered electronically to the email address provided. Name *FirstLastOrganization nameEmailPreviousNextThank you again Thank you for your time. If you requested to be contacted, a DisposeRx representative will reach out within 2 business days. Submit
