*** SEREDYN RETURN FORM - 30 DAY TRIAL ***

(30-Day Trial applies only to orders placed 
after Monday, April 25, and before Wednesday, 
July 6. Note that trial offer applies only to 
first-time orders of new customers, and only 
to orders for a single bottle.)

Please print, complete, and include this from
along with your return. As per the terms of the
trial, you may return up to one (1) open bottle
for a full refund. You must also include the
paper invoice (sent with your order) or a printed 
copy of your e-mail receipt

MAIL BOTTLE, QUESTIONNAIRE, & INVOICE TO:
  Bioneurix Corporation
  Attn: Seredyn Risk-Free Trial Return
  181 Marsh Hill Road
  Orange, CT 06477
  
 
DATE: ________________


(1) For what condition or reason did you decide to
try SEREDYN? (check all that apply)
___occasional anxiety
___chronic anxiety
___panic/anxiety attacks
___social anxiety
___phobia
___other (please explain) 	

(2) Would you still have purchased SEREDYN if you 
were not offered a risk-free money-back guarantee?
___Yes
___No
___Not sure

(3) How often do you take SEREDYN? (check one)
___More than three times per day
___Three times per day
___Twice per day
___Once per day
___Many times per week but not every day
___Once or twice per week
___Less than one per week

(4) How many capsules of SEREDYN do you generally 
take at once? (check one)
___One (1) capsule
___Two (2) capsules
___Three (3) capsules

(5) How many times did you take SEREDYN before 
deciding to return the bottles for a refund?

_____________________________________________________

(6) If you suffer from OCCASIONAL ANXIETY, how did
SEREDYN affect the severity of your anxiety? 
___Complete relief
___Significantly lessened
___Slightly lessened
___Same as before
___Worse than before
___Not applicable / I don't know

(7) If you suffer from CHRONIC ANXIETY, how did
SEREDYN affect the severity of your anxiety? 
___Complete relief
___Significantly lessened
___Slightly lessened
___Same as before
___Worse than before
___Not applicable / I don't know

(8) If you suffer from SOCIAL ANXIETY, how did
SEREDYN affect the severity of your anxiety? 
___Complete relief
___Significantly lessened
___Slightly lessened
___Same as before
___Worse than before
___Not applicable / I don't know

(9) If you suffer from PANIC/ANXIETY ATTACKS, how 
effective was SEREDYN at PREVENTING attacks?
___Extremely effective
___Somewhat effective
___Slightly effective
___Not effective
___Not applicable / I don't know

(10) If you suffer from PANIC/ANXIETY ATTACKS, how 
effective was SEREDYN at RELIEVING attacks (or 
reducing the severity of attacks) when taken once 
the attack had started?
___Extremely effective
___Somewhat effective
___Slightly effective
___Not effective
___Not applicable / I don't know

(11) Overall, how would you rate your experience 
with SEREDYN? (choose one)
___Extremely positive
___Somewhat positive
___Slightly positive
___Neutral
___Slightly negative
___Somewhat negative
___Extremely negative

(12) How would you rate the severity of side effects
you experienced while taking SEREDYN? (choose one)
___No side effects.
___Mild side effects.
___Moderate side effects.
___Severe side effects.

(13) Please indicate which side effects, if any, 
you experienced while taking SEREDYN:





(14) Why did you decide to stop using SEREDYN?
What could have been better about your experience?





(15) Do you have any additional comments or thoughts
that you'd like to share?





DELIVERY DATE OF ORDER____________________



NAME______________________________________

SHIP-TO ADDRESS___________________________

__________________________________________

CITY__________________STATE____ZIP________

EMAIL_____________________________________

PHONE______-______-________

CREDIT CARD USED TO PAY FOR ORDER:

CARD NUMBER______-______-______-______EXP____/____

NAME ON CARD______________________________________

BILLING ADDRESS___________________________________
               (if different from Ship-To Address)
               

Thank you for trying SEREDYN and taking the time
to fill out this questionnaire.  Once we receive
your return, we will issue a full refund to your
credit card within 48 hours.


MAIL BOTTLE, QUESTIONNAIRE, & INVOICE TO:
  Bioneurix Corporation
  Attn: Seredyn Risk-Free Trial Return
  181 Marsh Hill Road
  Orange, CT 06477