Thank you for taking the time to complete the Eucerin and Aquaphor® Professional online profile survey!
To assess your eligibility of receiving samples, please complete the following steps:
  • Enter your Registration ID on line 1 of the survey (if blank)
    Your Registration ID can be found at the bottom of the letter mailed to you.
    Once entered, the practice’s contact information will auto-fill in the appropriate fields.
  • Verify the address and contact information
  • Ensure all practice-specific questions are answered to the best of your ability
  • When finished, please click “submit” at the bottom
Note: if any of the required fields are left blank, your practice will not be eligible to receive samples.
Registration ID * 
Professional designation * 
First name * 
Last name * 
E-mail address * 
Confirm E-mail address * 
Institution or practice name * 
Is this office associated with Kaiser Permanente or Group Health? *        Yes       No
Mailing address line 1 * 
Mailing address line 2  
Mailing address line 3  
City *  State * 
Zip *   
Phone # *  Fax #  
1 *
Are you currently receiving samples of Eucerin and/or Aquaphor?
  Yes       No
2 *
Where are you currently receiving samples?
Home Institution or practice address
2 addresses 3+ addresses NA
3 *
Practice type Dermatology Pediatrics
4 *
Primary specialty General dermatology Dermatology or Mohs surgeon
  Cosmetic dermatology Pediatric dermatology
  General pediatrics
5 *
License type
License number
6 *
Number of practitioners at current location (including MD, NP, and PA)
1 2-4 5+
7 *
Number of patients you see per week (at this location)
1-50 51-100 101-150
151-200 201+
8 *
Primary patient conditions treated. [Please limit to 3 responses]
Dry skin/eczema Psoriasis Acne Rosacea
Anti-aging Cosmetic Melasma/hyperpigmentation
Skin cancer screening and/or treatment
9 *
Please rate the degree to which you recommend the following products:
10 *
Which of the following Eucerin lines do you typically recommend? Please select all that apply:
Aquaphor Healing Ointment
Eucerin Original Healing Lotion and/or Creme
Eucerin Professional Repair, Smoothing Repair, and/or Intensive Repair
Eucerin Skin Calming Body Wash, Skin Calming Creme, and/or
Eucerin Daily Protection Body Lotion SPF 15 and/or
Eucerin Daily Protection Face Lotion SPF 30
8 *
Survey completed by: Self  Office manager/staff
Sales representative
Opt-Out: I no longer wish to receive samples of Eucerin and Aquaphor from Beiersdorf, Inc.
* Required field