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First Name: |
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Last Name: |
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Mailing Address |
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City: |
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State: |
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Zip: |
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Email Address: |
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Birth Date MM/DD/YY |
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Due Date: |
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How many children currently in household: |
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Average Household Income: |
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Are you familiar with the benefits of gradient compression / support hosiery during pregnancy? |
Yes
No
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Have you worn gradient compression / support hosiery during pregnancy? |
Yes
No
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Pantyhose |
Very likely to purchase and wear
Would maybe purchase and wear
Highly unlikely to purchase and wear
Would NOT purchase wear
Would purchase and wear during certain seasons only
Would purchase and wear for special occasions only
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Footless Pantyhose |
Very likely to purchase and wear
Would maybe purchase and wear
Highly unlikely to purchase and wear
Would NOT purchase wear
Would purchase and wear during certain seasons only
Would purchase and wear for special occasions only
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Tights |
Very likely to purchase and wear
Would maybe purchase and wear
Highly unlikely to purchase and wear
Would NOT purchase wear
Would purchase and wear during certain seasons only
Would purchase and wear for special occasions only
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Footless Tights |
Very likely to purchase and wear
Would maybe purchase and wear
Highly unlikely to purchase and wear
Would NOT purchase wear
Would purchase and wear during certain seasons only
Would purchase and wear for special occasions only
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Knee-High Stockings |
Very likely to purchase and wear
Would maybe purchase and wear
Highly unlikely to purchase and wear
Would NOT purchase wear
Would purchase and wear during certain seasons only
Would purchase and wear for special occasions only
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Thigh-High Stockings |
Very likely to purchase and wear
Would maybe purchase and wear
Highly unlikely to purchase and wear
Would NOT purchase wear
Would purchase and wear during certain seasons only
Would purchase and wear for special occasions only
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Trouser Socks |
Very likely to purchase and wear
Would maybe purchase and wear
Highly unlikely to purchase and wear
Would NOT purchase wear
Would purchase and wear during certain seasons only
Would purchase and wear for special occasions only
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Over-the-calf Athletic Socks |
Very likely to purchase and wear
Would maybe purchase and wear
Highly unlikely to purchase and wear
Would NOT purchase wear
Would purchase and wear during certain seasons only
Would purchase and wear for special occasions only
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Footless Thigh-High Stockings |
Very likely to purchase and wear
Would maybe purchase and wear
Highly unlikely to purchase and wear
Would NOT purchase wear
Would purchase and wear during certain seasons only
Would purchase and wear for special occasions only
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Footless Knee-High Stockings |
Very likely to purchase and wear
Would maybe purchase and wear
Highly unlikely to purchase and wear
Would NOT purchase wear
Would purchase and wear during certain seasons only
Would purchase and wear for special occasions only
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Anklet |
Very likely to purchase and wear
Would maybe purchase and wear
Highly unlikely to purchase and wear
Would NOT purchase wear
Would purchase and wear during certain seasons only
Would purchase and wear for special occasions only
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Open-Toe Knee-High Stockings |
Very likely to purchase and wear
Would maybe purchase and wear
Highly unlikely to purchase and wear
Would NOT purchase wear
Would purchase and wear during certain seasons only
Would purchase and wear for special occasions only
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Open-Toe Thigh-High Stockings |
Very likely to purchase and wear
Would maybe purchase and wear
Highly unlikely to purchase and wear
Would NOT purchase wear
Would purchase and wear during certain seasons only
Would purchase and wear for special occasions only
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Other, please specify: |
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Check all colors of compression hosiery you would wear on a frequent,
everyday basis:
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Black
White
Winter White
Sand
Natural
Bronze
Cocoa
Coal
Indigo
Purple
Metallic Gold
Metallic Silver
Ice Blue
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Other, please specify: |
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Check all colors of compression hosiery you would wear for special occasions or seasonly only:
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Black
White
Winter White
Sand
Natural
Bronze
Cocoa
Coal
Indigo
Purple
Metallic Gold
Metallic Silver
Ice Blue
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Other, please specify: |
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Pantyhose |
$10-15
$15-20
$20-25
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Thigh-High |
$10-15
$15-20
$20-25
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Trouser Socks |
$7-10
$11-15
$16-20
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Where would you expect to find these products: |
Mass Retailer
Department Store
Boutique
Pharmacy
Online
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Other, please specify: |
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If you had to choose one retailer to go and purchase these products at, what retailer would you go to? |
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What other products might you purchase for wearing during and after pregnancy? |
Maternity support band
Postpartum compression garments
Other, please specify
None of the above
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Comments / Questions: |
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Choose style preference for test product |
Trouser Socks
Maternity Pantyhose
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Specify Size for Trouser Sock |
Small – Shoe Size 5-8
Medium – Shoe Size 8.5-11
Large/Full Calf – Shoe Size 7-10
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Specify Size for Pantyhose (See Size Chart Below. Sizes are based on pre-pregnancy weight.)
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Small
Medium
Large
X-Large
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How did you hear about Preggers by Therafirm? |
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Would you like to receive future updates on our maternity product line? |
Yes
No
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