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Feedback Form For Medical Representative / Manager

Fields marked with are mandatory

Name of MR / Manager:

Name of The Company :

Local Address of The Company :

Address of MR / Manager :

Contact No.:

E-mail :

Name of the Dr. prescribing
your product :

Name of the fast moving product :

Name of the fast moving product
in this area:

Availability :

Poor GoodVery Good

If poor then give remarks for improvement

Name of the products to be introduced
in this area :

Give details of Bonus offer your company is giving to the retailer and wholesaler :

Any display or sales promotion program your company is interested in our store :

Any event your company would like to organise in our store (eg.) Diabetic camp, Lung Function Test, Well Baby Show etc.:

Please give the detail of such
program with approximate no. of
person taking part :

Any other kind of specific feedback required by you gives reasons
and details :

Remarks / Suggestions for joint promotional efforts :

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