Rescue Retention Form

Name:

First NameLast Name

Preferred Distributor:

Clinic Name:

Clinic Address:

Street Address

Street Address Line 2

CityState

Zip Code

Email Address:

Phone Number:

Format: (000) 000-0000.

Do you actively use Rescue Disinfectants?

Please select which products you currently buy:

Please select the reason you no longer purchase. (Check all that apply)

What disinfectant do you currently use?

What Rescue products are you interested in learning more about?

In your opinion, what are the TOP THREE benefits of the Virox line of Rescue products?

Other

What triggered your decision to buy Rescue?

Do you currently have a written disinfectant protocol set up in your facility?

The protocol was created by

Are you interested in creating a free customized protocol?

Which of the following Rescue resources are you familiar with? (Check all that apply)

Do you want to schedule a video conference call to answer questions about Rescue Disinfectants and best practices for your facility?