Requires the following confirmation statement:

"I confirm that I have cystic fibrosis or immotile ciliary syndrome, or that I am filling out this paperwork on behalf of my parents or child or spouse. I understand that my personal information will be kept confidential at NeilMed and will not be given to any other company for marketing purposes. However, I also understand that NeilMed may send complimentary samples to my doctors for the benefit of other patients."

NeilMed Pharmaceuticals, Makers of Sinus Rinse, NasaFlo Netipot, Nasal Irrigation

Slightly different than thier last offers