Fill out the form below to receive updates as new Doc & Diva chats and information about Vivelle-Dot® (estradiol transdermal system) become available
By filling out this form, you specifically authorize Novogyne Pharmaceuticals to send you updates on the latest Doc & Diva chats. If you so indicate below, it may also be used in accordance with our Privacy Policy to send you additional information about menopause or Vivelle-Dot, or to contact you.
Please keep in mind that only your doctor can prescribe Vivelle-Dot. However, Vivelle-Dot is not for everyone. Talk to your doctor about what treatment may be right for you. Please see Important Safety Information for more details.
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Personal Information
Tell Us About Your Experience with Estrogen Therapy (ET)
Please answer the following questions so that we can continue to provide relevant and useful information.
Have you ever used a prescription ET medication? You must have received a prescription from your doctor to receive this medication.
Yes, currently usingUsed to but not currentlyNever
*On a scale of 1 to 7, where 7 is "extremely interested" and 1 is "not at all interested," how interested would you be in an estrogen therapy treatment that is delivered as a skin patch?
1 2 3 4 5 6 7
*On a scale of 1 to 7, where 7 means you “strongly agree" and 1 means you "strongly disagree," please indicate how much you agree or disagree with the following statement. I understand the risks/benefits associated with estrogen therapy.
*On a scale of 1 to 7, where 7 is "extremely satisfied" and 1 is "extremely dissatisfied," how satisfied are you with your current prescription estrogen therapy medication? (If you are not currently taking a prescription ET medication, please indicate your level of satisfaction with your previous prescription ET medication).
On a scale of 1 to 7, where 7 means you "strongly agree" and 1 means you "strongly disagree," please indicate how much you agree or disagree with the following statement. I take an active role in managing my own health.
*In the past month, have you experienced moderate to severe hot flashes and/or night sweats as a symptom of menopause?
YesNoNot sure
*Do you currently exercise to manage your symptoms associated with menopause?
*On a scale of 1 to 7, where 7 is "extremely interested" and 1 is "not at all interested," how interested would you be in an estrogen therapy treatment that is delivered as:
*On a scale of 1 to 7, where 7 is "extremely likely" and 1 is "not at all likely," how likely are you - during the next 6 months - to ask your doctor if an estrogen therapy medication may be appropriate for you?
*I acknowledge that I am 18 years of age or older. YesNo
Yes, I'd like to receive additional information in the future from Novogyne about menopause or Vivelle-Dot.
Yes, the information I provided here may be used by Novogyne Pharmaceuticals to contact me in the future.
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