Nasal Valve Support™

Any surgeries on your nose including sinuses? *

Yes

No

While gently lifting the side wall of your LEFT nostril, that is, while pulling it away from the middle wall of your nose, please explain how the airflow through your LEFT nostril improves: *

Major improvement

Little or no improvement

Please repeat the above for your RIGHT nostril: *

Major improvement

Little or no improvement

Name *

First Name

Last Name

Gender *

Female

Male

Date of Birth *

MM

DD

YYYY

Phone number *

Country

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