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Name :
Gender :     M
Email :
Age :
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Address :
Phone Number :
How long have you beensmoking ? (No: of years) :
No: of cigar/beedi/other tobacco items you use in a day ? :
:




Have you tried any other product to quit smoking ?. If Yes :

Name of the Product :
Period :
Was it effective  



About Anticig
How did you know about Anticig ? :
How many tablets consumed per day ? :                           
10-20        20-30      30-40     40>
How many days did it take to get an effective result ?                             
10-20        20-30      30-40     40>





How do you feel about Anticig ?
Taste :
Efficacy :
Price :

Would you prefer to suggest this product to any of your friend, who wish to quit smoking ?
Name :
Phone :
Any other suggestions :
     
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