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713-621-7944

Walmart Equate Phenylephrine Decongestant Questionnaire

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- Step 1 of 5

Name of Person Filling Out This Form *

Client Name (Who Purchased Item) *

First

Last

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Maiden Name (if applicable)

Other Names Used

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Client Email *

Client Home Phone Number

Client Cell Phone Number *

Client Work Phone Number

Client Information

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Client Mailing Address *

Address Line 1

City

State

Zip Code

Is this an Apartment/Unit or a House? *

Apartment
Condo/Unit
House/Townhome

What is the Unit or Apartment Number?

Client Date of Birth *

Client Social Security Number

Have you (or they) ever filed or are currently involved in any bankruptcy proceeding? *

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When?

What is the status of the bankruptcy?

In the last 10 years, were you convicted of a crime? *

If yes, list the crime and date:

Alternate Contact (For Emergency Contact Only)

Emergency Contact #1 *

First

Middle

Last

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Address (Emergency Contact) *

Address Line 1

City

State

Zip Code

Cell Phone Number (Emergency Contact) *

Home Phone Number (Emergency Contact)

Work Phone Number (Emergency Contact)

Product Use:

Which item did you purchase? (Check all that apply): *

Equate Daytime & Nighttime Relief Value Pack, 6/5 Packets
Equate Daytime, Cold & Flu, 24 Softgels
Equate Nighttime VAPOR ICE, Cold & Flu, 24 Caplets
Equate Children’s Cold & Cough, Grape Syrup
Equate Daytime VAPOR ICE, Cold & Flu, 24 Caplets
Equate VAPOR ICE, Cold & Flu, 16/8 Caplets

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Do you still have the product and packaging? *

Do you have a receipt for the Equate purchase?

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713-621-7944

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