First Name
Last Name
Email
Address
Address 2
City
State/Province
Zip/Postal Code
Telephone
How did you hear about Instead?
Friend/Family
Doctor
Television
Online
Magazine
In a Store
Other
Have you ever used Instead before?
Yes
No
If so, what is your favorite thing about Instead?
(Please select only 2)
More comfortable than tampons/pads
Longer wear time
I can be more active
Clean sex during my period
Does not irritate me or dry me out
No Odor
I don’t have to worry about TSS (Toxic Shock Syndrome)
Easy to insert/remove
How old are you?
Under 14
15-18
19-29
30-39
40-49
50-59
60 and above
What is the best way to contact you?
Email
Telephone
Postal Mail
