* First Name * Last Name * Email * Your Phone Number: * MDCN Registration Number: Address Address Line 1 Address Line 2 City State Zip Code Country Afghanistan Åland IslandsAlbania AlgeriaAmerican Samoa AndorraAngola AnguillaAntarcticaAntigua and Barbuda ArgentinaArmeniaAruba AustraliaAustriaAzerbaijan BahamasBahrainBangladesh BarbadosBelarusBelgiumBelau BelizeBeninBermudaBhutan BoliviaBonaire, Saint Eustatius and SabaBosnia and Herzegovina BotswanaBouvet IslandBrazil British Indian Ocean TerritoryBritish Virgin Islands BruneiBulgariaBurkina Faso BurundiCambodiaCameroon CanadaCape VerdeCayman Islands Central African RepublicChadChile ChinaChristmas IslandCocos (Keeling) Islands ColombiaComorosCongo (Brazzaville) Congo (Kinshasa)Cook IslandsCosta Rica CroatiaCubaCuraçao CyprusCzech RepublicDenmark DjiboutiDominicaDominican Republic EcuadorEgyptEl SalvadorEquatorial Guinea EritreaEstoniaEthiopiaFalkland Islands Faroe IslandsFijiFinlandFrance French GuianaFrench PolynesiaFrench Southern Territories GabonGambiaGeorgiaGermany GhanaGibraltarGreeceGreenland GrenadaGuadeloupeGuamGuatemalaGuernsey GuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald Islands HondurasHong KongHungaryIcelandIndia IndonesiaIranIraqIreland Isle of ManIsraelItalyIvory CoastJamaica JapanJerseyJordanKazakhstan KenyaKiribatiKuwaitKyrgyzstan LaosLatviaLebanonLesotho LiberiaLibyaLiechtensteinLithuaniaLuxembourg Macao S.A.R., ChinaMacedoniaMadagascar MalawiMalaysiaMaldivesMali MaltaMarshall IslandsMartinique MauritaniaMauritiusMayotte Mexico MicronesiaMoldovaMonaco MongoliaMontenegroMontserrat MoroccoMozambiqueMyanmar NamibiaNauruNepal NetherlandsNew CaledoniaNew Zealand NicaraguaNigerNigeriaNiue Norfolk IslandNorthern Mariana IslandsNorth Korea NorwayOmanPakistanPalestinian Territory PanamaPapua New GuineaParaguay Peru PhilippinesPitcairnPoland PortugalPuerto RicoQatar ReunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Martin (Dutch part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSan MarinoSão Tomé and PríncipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia/Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-Leste TogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab Emirates United Kingdom (UK)United States (US)United States (US) Minor Outlying IslandsUnited States (US) Virgin Islands UruguayUzbekistanVanuatuVaticanVenezuelaVietnamWallis and FutunaWestern SaharaSamoaYemenZambiaZimbabwe Your main specialty Your second specialty/interest (if any) Are you visited by Pharmaceutical Representatives promoting their products? Yes No If ‘Yes’, what product were you last briefed on by a Pharmaceutical Representative? Do you attend CME (Continuing Medical Education) Meetings? Yes No Do you get information about Drugs or Medical Devices during CME Meetings? Yes No Where do you get most Pharmaceutical Drug Information from? Pharmacists / Rep visits Medical / CME Meetings What percentage (%) of pharmaceutical knowledge do you receive from CME Meetings? Do you use a Prescribing Software at your practice during consulting? Yes No What company supplies the software? If ‘yes’, what software packages do you use? Have you participated in any Healthcare Market Research before? Yes No If ‘Yes’, when was your last participation and what Drug or Topic was the focus? Did you participate on-line, by telephone or hand-written? Would you be interested in participating in Healthcare Market Research in the future? Yes No * I have read and agreed to the terms and conditions.