RebiSmart

By submitting this form, you provide permission to rebismart.ca to add your name to a subscriber list to receive ongoing information updates and new educational material on RebiSmart™. EMD Serono Canada Inc. also periodically conducts research in order to better understand the needs of those with MS, and may contact you in the future regarding any research surveys that are conducted and/or to assist with changes and improvements to RebiSmart™ education activities. You may opt out of these communications at any time.

General contact information

First Name*	Last Name*
Email*	Confirm Email*
City	Province
Phone	Neurologist's Name

Please tell us a bit more about yourself

1. How long ago were you diagnosed with MS?

Diagnosis pending
Less than 3 months
3–6 months
6 months–1 year
1–2 years
3–5 years
6–10 years
11–20 years
20+ years

2. Are you currently being treated for MS with a disease-modifying therapy (e.g., Avonex^®, Betaseron^®, Copaxone^®, Rebif^®, or Tysabri^®)?

Yes for approximately years
No

3. If you are using or have used disease modifying therapy, what injection method(s) do/did you use? (select all that apply)

Subcutaneous (just under the skin) with an autoinjector
Subcutaneous (just under the skin) with traditional syringe/needle
Intramuscular (into the muscle) with an autoinjector
Intramuscular (into the muscle) with traditional syringe/needle
Intravenous (performed at a clinic)
I don't know

4. If you are using or have used disease-modifying therapy, what is the most difficult part of your injections? (select all that apply)

Painful/uncomfortable injection
Experience injection-site reactions
Don't like current injection device
Anxious or uncomfortable with needles
Getting tired of traditional injections
Other

5. What benefits of RebiSmart™ are you most interested in? (select all that apply)

Convenience
Ease of use
Personalized therapy
Control over your injections
Help with monitoring your therapy schedule
Improved therapy experience

6. How did you hear about RebiSmart™?

Information in clinic waiting room
Healthcare team provided information
Friend/relative/word of mouth
Media (radio, TV, newspaper/magazine)
General internet search
Internet, please specify website:
Other, please specify:

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