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Give Us Feedback or Submit a Question

Your feedback is valuable to us. Please use the form below to share your Alcortin experience or to submit any requests or questions. If you experienced or are experiencing an adverse event to Alcortin, contact your physician immediately and report it to Primus using the form below.

First Name
*
Last Name
*
Address 1
Address 2
City
State
Zip
Email
*
Telephone
How many weeks have you been using Alcortin?
(Enter 0 if you have not used Alcortin)
How did you hear about Alcortin?
(Check all that apply)
Physician
Pharmacist
Physician Assistant
Nurse Practitioner
Family Member
Friend
Internet
Advertisement
Article or Interview
Other (please write in)
Tell us how it felt to live with your condition before you tried Alcortin?
Tell us how it felt to live with your condition after you tried Alcortin?
Questions about Alcortin?
Which improvements did you notice after taking Alcortin?
(Check all that apply)
Less Inflammation
Other Improvement(s):
How soon did you notice the above improvements after taking Alcortin?
Which medication were you most recently taking to treat your condition mentioned above?
(Check all that apply)
Loprox® (ciclopirox)
Lotrisone® (clotrimazole & betamethasone dipropionate)
Oxistat® (oxiconazole)
Mentax® (butenafine hcl)
Other medication
None of the above
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Physician First Name
Physician Last Name
Physician Address 1
Physician Address 2
Physician City
Physician State
Physician Zip
Physician Telephone
You have my permission to contact my doctor listed here regarding my feedback.
Please contact me to discuss my feedback on Alcortin.
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