CSO(Required)Select CSOFranCarlaAngelaNicolaCaroleDoes the customer buy extra products in addition to their home delivery NHS order?(Required) Yes No Where are they buying extra products?Please Choose...SupermarketPharmacyOnline shopAmazonHartmann DirectWhich brand are they buying?Please Choose...MoliCareTENAAlwaysIDAbenaAttendsSupermarket own brandOtherThey don’t knowWhich Brand? How frequently do they buy extra products?Please Choose...WeeklyMonthlyAs and when they needWould you be interested in buying MoliCare® extra supplies directly from us? We are offering a special discount for NHS patients(Required)Please Choose...YesNoNot currently but maybe in the futureCall back timePlease Choose...MorningAfternoonEveningCallback Date MM slash DD slash YYYY Would the customer like to join our email marketing mailing list? READ STATEMENT TO CUSTOMER "Would you like to subscribe to our HARTMANN GROUP email marketing mailing list, to receive the latest news, offers and incontinence advice. We will only use your information for this purpose, and your data will not be shared with any third parties. If you change your mind you can chose to opt out at any time."Are you..(Required) Caregiver Person with Incontinence Customer Name(Required) First Last Home Delivery ID Email Address Phone Number Δ
