BRANCH CODE/NUMBER: ______________

SURVEY FORM
SURVEY FORM DATA PRIVACY: I understand Southstar Drug's Data Privacy Statement which can be found in
https://southstardrug.com.ph/policies/privacy-policy and express my consent for the Southstar Drug Inc. to collect, record, organize,
update or modify, retrieve, consult, use, consolidate, block, erase or destruct my personal data as part of my information. I hereby
affirm my right to be informed, object to processing, access and rectify, suspend or withdraw my personal data, and be indemnified
in case of damages pursuant to the provisions of the Republic Act No. 10173 of the Philippines, Data Privacy Act of 2012 and its
corresponding Implementing Rules and Regulations.

Name / Pangalan (Optional): Age / Edad:

City / Municipality Address: Sex / Kasarian:

Shade the circle next to the option most applicable to you.

I-shade ang bilog sa tabi ng opsyong pinaka-angkop sa iyo.

1. What is the frequency of your O Daily O Weekly O Monthly

purchase for medicines?
(Araw-araw) (Lingguhan) (Buwanan)
Ano ang dalas ng iyong pagbili
ng mga gamot?

2. Would you prefer to purchase O In-store Purchase O Deliver to home/work

your medicines inside the
(Bumili sa loob ng botika) (Ihatid sa bahay/trabaho)
drugstore or delivered to you?

Mas gusto mo bang bilhin ang

iyong mga gamot sa loob ng
botika o ihahatid sa iyo?

3. Would you like to receive O Yes (Oo) O No (Hindi)

updates and promos from South
Star Drug?
Contact: ___________________
Gusto mo bang makatanggap at
mga update, at mga promo mula
sa South Star Drug?

Frequent product(s) purchased. / Produktong madalas bilhin.

O Maintenance Medicine O Vitamins/Minerals O Milk O Others