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6-12-2006, 5:07 AM
Register to get the answers you need about acid reflux disease—and a $2.00 check!
With Straight Forward news and information delivered conveniently by e-mail, you'll have helpful, interesting answers to your questions about acid reflux disease—right at your fingertips. And when you register online, you'll get a $2.00 check besides!
Complete the form below to get up-to-date e-mail news and tips—and your information will be on its way. By learning more about what you've experienced, we'll be sure to send you the news, support and additional savings that can help.
https://www.straightforwardaciphex.com/default.asp?SourceID
Register to get the answers you need about acid reflux disease—and a $2.00 check!
With Straight Forward news and information delivered conveniently by e-mail, you'll have helpful, interesting answers to your questions about acid reflux disease—right at your fingertips. And when you register online, you'll get a $2.00 check besides!
Complete the form below to get up-to-date e-mail news and tips—and your information will be on its way. By learning more about what you've experienced, we'll be sure to send you the news, support and additional savings that can help.
Important Notice: Use of your personal information
By voluntarily providing your Date of Birth and gender, you are giving your consent that Eisai Inc. and Janssen Pharmaceutica Inc., their affiliates and companies working for them will use your personal information to evaluate the effectiveness of the educational program, but your information will first be de-identified so that neither Eisai nor Janssen, nor the companies working for them, will be able to identify you when they conduct this evaluation.
You acknowledge your understanding and consent that the information you provide will be used and disclosed to Eisai Inc. and Janssen Pharmaceutica Inc., their affiliates and companies working for them for the following purposes: (1) To send you educational materials. (2) If you choose to complete the voluntary survey, information collected from you will be used to send you tailored health and other information, including information on ACIPHEX. We respect your privacy; the personal and health information you provide will be used solely for the above purposes, and will not be disclosed to entities other than Eisai, Janssen, their affiliates and companies working for them. You must be 18 years or older to participate. The program is only offered within the U.S. You can request that your information be removed at any time from our contact list by calling 1-866-4-ACIPHEX. For further information please see privacy policy below.
* By clicking on the “I Accept” button below, you agree that the information you submit will be governed by the Important Notice above and our Privacy Policy.
I Accept I Decline
You must be 18 or older and currently taking ACIPHEX in order to participate in this program. Thank you for your interest.
You have entered incomplete or incorrect information in the fields indicated below. Please review your entries. When you are ready, click the Submit button below.
*Indicates required field. E-mail address and registration required to receive your $2.00 check.
* Are you 18 years or older?
Yes No
* Are you currently taking ACIPHEX?
Yes No
*First Name:
*Last Name:
*Address:
Address 2:
*City:
*State: *ZIP:
Date of Birth:
Gender: Male Female
* E-mail Address:
* Verify E-mail Address:
(Providing your e-mail address allows us to communicate with you via U.S. mail and/or e-mail.)
1. How long have you been taking ACIPHEX?
Less than 3 months
4 months or more
2. How often do you take ACIPHEX?
Less than once a week
Once a week
2 - 3 times a week
4 - 5 times a week
6 or more times a week
3. How often do you experience symptoms related to your condition?
Less than once a week
Once a week
2 - 3 times a week
4 - 5 times a week
6 or more times a week
4. When treating my heartburn, I typically take a prescription medication each day.
Disagree Completely 1 2 3 4 5 6 Agree Completely
5. My heartburn has taken a lot of freedom and enjoyment out of my life.
Disagree Completely 1 2 3 4 5 6 Agree Completely
6. My doctor has been very helpful in getting my heartburn under control.
Disagree Completely 1 2 3 4 5 6 Agree Completely
7. Whether or not I take medication depends on my symptoms.
Disagree Completely 1 2 3 4 5 6 Agree Completely
ACIPHEX
With Straight Forward news and information delivered conveniently by e-mail, you'll have helpful, interesting answers to your questions about acid reflux disease—right at your fingertips. And when you register online, you'll get a $2.00 check besides!
Complete the form below to get up-to-date e-mail news and tips—and your information will be on its way. By learning more about what you've experienced, we'll be sure to send you the news, support and additional savings that can help.
https://www.straightforwardaciphex.com/default.asp?SourceID
Register to get the answers you need about acid reflux disease—and a $2.00 check!
With Straight Forward news and information delivered conveniently by e-mail, you'll have helpful, interesting answers to your questions about acid reflux disease—right at your fingertips. And when you register online, you'll get a $2.00 check besides!
Complete the form below to get up-to-date e-mail news and tips—and your information will be on its way. By learning more about what you've experienced, we'll be sure to send you the news, support and additional savings that can help.
Important Notice: Use of your personal information
By voluntarily providing your Date of Birth and gender, you are giving your consent that Eisai Inc. and Janssen Pharmaceutica Inc., their affiliates and companies working for them will use your personal information to evaluate the effectiveness of the educational program, but your information will first be de-identified so that neither Eisai nor Janssen, nor the companies working for them, will be able to identify you when they conduct this evaluation.
You acknowledge your understanding and consent that the information you provide will be used and disclosed to Eisai Inc. and Janssen Pharmaceutica Inc., their affiliates and companies working for them for the following purposes: (1) To send you educational materials. (2) If you choose to complete the voluntary survey, information collected from you will be used to send you tailored health and other information, including information on ACIPHEX. We respect your privacy; the personal and health information you provide will be used solely for the above purposes, and will not be disclosed to entities other than Eisai, Janssen, their affiliates and companies working for them. You must be 18 years or older to participate. The program is only offered within the U.S. You can request that your information be removed at any time from our contact list by calling 1-866-4-ACIPHEX. For further information please see privacy policy below.
* By clicking on the “I Accept” button below, you agree that the information you submit will be governed by the Important Notice above and our Privacy Policy.
I Accept I Decline
You must be 18 or older and currently taking ACIPHEX in order to participate in this program. Thank you for your interest.
You have entered incomplete or incorrect information in the fields indicated below. Please review your entries. When you are ready, click the Submit button below.
*Indicates required field. E-mail address and registration required to receive your $2.00 check.
* Are you 18 years or older?
Yes No
* Are you currently taking ACIPHEX?
Yes No
*First Name:
*Last Name:
*Address:
Address 2:
*City:
*State: *ZIP:
Date of Birth:
Gender: Male Female
* E-mail Address:
* Verify E-mail Address:
(Providing your e-mail address allows us to communicate with you via U.S. mail and/or e-mail.)
1. How long have you been taking ACIPHEX?
Less than 3 months
4 months or more
2. How often do you take ACIPHEX?
Less than once a week
Once a week
2 - 3 times a week
4 - 5 times a week
6 or more times a week
3. How often do you experience symptoms related to your condition?
Less than once a week
Once a week
2 - 3 times a week
4 - 5 times a week
6 or more times a week
4. When treating my heartburn, I typically take a prescription medication each day.
Disagree Completely 1 2 3 4 5 6 Agree Completely
5. My heartburn has taken a lot of freedom and enjoyment out of my life.
Disagree Completely 1 2 3 4 5 6 Agree Completely
6. My doctor has been very helpful in getting my heartburn under control.
Disagree Completely 1 2 3 4 5 6 Agree Completely
7. Whether or not I take medication depends on my symptoms.
Disagree Completely 1 2 3 4 5 6 Agree Completely
ACIPHEX