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skincare to set yourself free
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Dry Skin Sample Request

For a free Eucerin® sample, please complete your details and return this questionnaire.
(Available to UK and Republic of Ireland residents only).

The more we know about you and your skin condition the more able we will be to meet your skincare needs and create products which focus on your and your family's specific skincare problems.

The samples you have requested will be sent to you shortly. If the product you have requested are not currently available, we will send you an alternative.

(Unfortunately, we can not supply Intensive 10% Urea Treatment products as samples)


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  House Name / Number
  Address Line 1
  Address Line 2
  Town/City
  County
  Postcode e.g. AB10 2CD
  Country
 
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red Your Details   Title
  First Name
  Last Name
  Date of Birth      
  Sex
  Email Address
 
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Do you, or any members(s) of you family suffer from any of the following skin conditions?

(Please tick all that apply)

Dry skin

 Very dry skin Itchy, irritated skin
Skin that peels easily

Scaly, itchy and red skin Tight skin
Chapped, cracked or scaling skin        
 
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Does this condition affect:

(Please tick all that apply)

Yourself Your Partner Your child/grandchild
Other Relative Other
   

If the condition does not affect yourself, please answer the following questions concerning the person with the skin condition.
 
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Which part of your body does this skin condition affect

Scalp Face Body
Arms/Legs Hands Feet
   

If the condition does not affect yourself, please answer the following questions concerning the person with the skin condition.
 
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Who do you ask for advice for the treatment of this skin condition(s)?

(Please tick all that apply)

If you are already using prescribed treatments please contact your GP or Pharmacist before using new products
GP Dermatologist Practice Nurse
Pharmacist Fellow Sufferer Friend/Relative
Skincare Advisor Not Sought Advice
 
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red Do you use specially designed treatments for these parts of your body?   
 
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red Do you currently use any of these brands to treat this?
E45 Oilatum Aveeno Eumobase
Diprobase Eumovate Balneum Eurax
Calmurid Aquadrate Vaseline Neutrogena
Cetraben Doublebase Epaderm Boots Own Brand
 
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red Are you satisfied with your current product(s)?   
 
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red How often do you apply this cream?   
 
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red When is your skin condition most likely to flare up?
Spring Summer Autumn Winter
Same Throughout Year
 
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red From which retailer do you usually purchase your skincare products?
(UK Residents only)
Local Chemist Lloyds Boots Superdrug
Waitrose Tesco Asda Morrisons
Sainsbury Other
 
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red Where did you hear about Eucerin?   
 
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red Which Sample are you interested in:

A maximum of two samples may be requested.		 Dry skin Foot Cream Dry Skin Relief Face Cream
Eucerin 5% Urea Cream Dry Skin Shampoo
Bath & Shower Therapy
Dry Skin Replenishing Face Cream Night
 
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Data Protection
Eucerin is a Beiersdorf Company and will not share any of your details with third parties. We would like to keep you informed of new products that may be useful to you.

If you do wish to receive further communications from Beiersdorf, then please indicate here.

Please contact me by email
Please contact me by post
 
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