Rx Reminder Email Engagement Form
Help us improve your medication reminder experience by sharing your preferences and feedback.
Full Name
*
First Name
Last Name
Email Address (for receiving reminders)
*
example@example.com
Phone Number (optional, for backup reminders)
Please enter a valid phone number.
Format: (000) 000-0000.
What is the name of your current prescription medication(s)?
*
How often do you need to take your medication?
*
Please Select
Once daily
Twice daily
Three times daily
Weekly
Other
Do you currently receive email reminders for your prescription?
*
Yes
No
What is your preferred frequency for receiving reminder emails?
*
Every dose
Once daily
Once weekly
Only when a dose is missed
Other
How helpful do you find the current reminder emails?
*
1
2
3
4
5
Which communication channels would you prefer for reminders? (Select all that apply)
*
Email
SMS/Text Message
Phone Call
Mobile App Notification
Other
Please share any suggestions to improve our prescription reminder service.
Submit
Should be Empty: