Questionnaire

Please fill out the following questionnaire

It will help us help you with information on Cartia and cardiovascular disease management.

*Mandatory fields

Age*

Have you had a

	Heart attack
	Stroke
	Other cardiovascular event

What low dose aspirin are you taking?*

If yes, who recommended Cartia to you

	Doctor
	Pharmacist
	Pharmacy Assistant
	Other

Would you like to be on our mailing list to receive information and offers from Cartia?

	Yes - please contact me via email
	Yes - please contact me via post

Name

Postal Address

Email Address

Thank you for completing our questionnaire

image of a Cartia pill Cartia is designed to protect your stomach.

Your name

Your email address

Thank you for registering

ALWAYS READ THE LABEL. Use only as directed. Seek doctor's advice before use as part of an overall program to manage risk of heart attack or stroke.
Cartia® and Duentric® are registered trade marks of the GlaxoSmithKline group of companies
© 2009 GlaxoSmithKline Australia Pty Ltd - All Rights Reserved

Questionnaire

Please fill out the following questionnaire

Your name

Your email address

About Cartia

Your Health

Post Heart Attack

Post Stroke

Other Conditions

Questionnaire

For Carers