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Dry Skin
Sensitive Facial Skin

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Sensitive Facial 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.

Address

House Name / Number

Address Line 1

Address Line 2

Town/City

County

Postcode

e.g. AB10 2CD

Country

Your Details

Title

First Name

Last Name

Date of Birth

Sex

Email Address

Do you, or any members(s) of you family suffer from any of the
following skin conditions?

(Please tick all that apply)

	Certain ingredients cause your skin to burn or redden		Certain ingredients cause allergic reactions		You flush easily and often
	Your skin is dry, fragile and translucent		Your skin tingles and feels tight		Your skin often over-reacts to external factors such as stress, shaving etc

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.

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

Do you use specially designed treatments for these parts of your body?

Do you currently use any of these brands to treat this?

Avene	A-derma	Simple
NIVEA	Oil of Olay	Boots Own Brand

When is your skin condition most likely to flare up?

Spring	Summer	Autumn	Winter
Same Throughout Year

From which retailer do you usually purchase your skincare products?
(UK Residents only)

Local Chemist	Lloyds	Boots	Superdrug
Waitrose	Tesco	Asda	Morrisons
Sainsbury	Other

Where did you hear about Eucerin?

Which Sample are you interested in:

Hydro-Protect Hydro-Balance

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.

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