Zipline Home Delivery Research

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Welcome and thank you for your willingness to support Zipline's research.

We’re conducting a survey for Zipline to help us understand home delivery of specialty pharmaceutical products. The results of this survey will be used to help Zipline improve the quality of services it provides to people like you.

Qualified participants would be anyone who is receiving home delivery of Specialty Pharmaceuticals or from Specialty Pharmacies. Specialty Pharmaceuticals are therapies that are high cost (more than $1,000/mo), highly complex, or require specialized handling or administration.

We ask that you ensure you meet the above criteria before completing the survey. We will not be able to accept responses from people who do not currently receive deliveries from specialty pharmacies.

For more information about Zipline, please visit us at www.flyzipline.com or reach out to Nick Hu directly at nick@flyzipline.com

Consent Form

Thank you for agreeing to participate in a survey ("Survey") administered by Zipline International Inc. ("Zipline", "we", ”our" or "us"). We appreciate your participation. The purpose of our Survey is for us to learn more about what recipients of pharmaceutical home-delivery services (like you) enjoy and dislike about those services. We want to know more because we are committed to improving the future experiences of people like you.

You are invited to participate in our Survey because we understand that you may use pharmaceutical home-delivery services. As a result, we hope that you may be able to provide us with valuable insight, feedback, and suggestions about your experience with those services. We know that completing our Survey takes time; in return for your efforts, Zipline will provide you with an Amazon.com gift card valued at $15 if you meet the qualification criteria. If your responses indicate you are not qualified, we will not send you an Amazon gift card.

Your participation in our Survey is voluntary. You may choose at any time not to participate in our Survey. If you decide for any reason not to participate in our Survey, you will not be penalized. [If you complete our Survey and later communicate to us that you no longer wish for Zipline to use the information you provided in connection with our Survey, we will use our best efforts to cease all use of and delete that information.]

Any responses, statements, or information that you provide to Zipline (including Zipline personnel) in connection with our Survey will remain confidential. All information about you will be stored in password-protected electronic format on our secured systems. Zipline will not identify you (including your name, email address, residential address, telephone number, or IP address) without your prior consent.

We are administering our Survey, and using information collected in connection with it, solely for our internal purposes and to improve Zipline's (and our affiliates') delivery and logistics products and services. Following the completion of the Survey, and upon your request, Zipline will share final results or learnings from our Survey, if any.

If you have any questions about our Survey or this Consent Agreement, please email legal@flyzipline.com or contact Nick Hu at +1 (415) 787-5411.

Consent Form *

I hereby agree and affirm that I am at least eighteen (18) years of age and am freely signing this Consent Agreement and participating in the Survey. I have read this Consent Agreement in its entirety and fully understand that by signing this Consent Agreement, I may be giving up legal rights and/or remedies that may be available to me against Zipline.

Required

Digital Signature *

Please enter your full name

Do you currently receive delivery of drugs from a specialty pharmacy? *

Specialty drugs or specialty pharmaceuticals are a recent designation of pharmaceuticals that are classified as high-cost, high complexity and/or high touch. Specialty drugs are often biologics —"drugs derived from living cells" that are injectable or infused (although some are oral medications)

Yes

Clear form

Never submit passwords through Google Forms.

This form was created inside of Zipline. Report Abuse

Forms