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Pain Remedy Trial!

Thank you for your interest in trying our NEW pain remedy. If you agree with all of the below requirements, please complete your details.

THANK YOU IN ADVANCE!

Please tick to confirm that you agree to the following
You agree that*
- You are experiencing pain that is impacting on your sleep
- You do NOT have a prescription of pain medication from your doctor
  (other than the following which ARE acceptable Paracetamol, Ibuprofen, Naproxen, Aspirin or Celebrex)
- You are willing to complete a Trial Diary for 4 weeks whilst using our natural herbal pain remedy
- You are ready to start immediately when the product arrives
- This product trial is for residents of New Zealand ONLY

Please complete the following
Name*
First Name Last Name
Email*
Phone*
Age*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Please complete the following
Type of pain experienced:*
How long you have been experiencing pain:
Are you currently taking medications for this pain?
- Yes
- No
If yes, what?
Were you previously taking medications for this pain?
- Yes
- No
Date
MM slash DD slash YYYY
Hidden
If yes, when?
What did you take?
Are you taking any other type of medications?
- Yes
- No
What did you take?
Do you have any other health conditions?
- Yes
- No
What did you take?
Consent
I agree to being a participant of the SleepDrops new product trial.
Name
This field is for validation purposes and should be left unchanged.

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Media Events Email Us 9:30 - 17: 30

Scientific Research Contract Manufacturing Visit our factory shop

Terms & Condition Privacy Policy Warranties & Return Policy Shipping Policy

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