Thank you for taking the time to complete the Eucerin and Aquaphor® Professional online survey! To continue receiving
your Eucerin and Aquaphor samples and ensure your enrollment in this program, please complete the following steps:
  • Answer all of the practice-based questions below to the best of your ability
  • Enter your registration ID on line 1 of this survey. Your registration ID can be found at the top of the printed
    survey. Once you do this, the address of your practice will appear in the appropriate field. If your address is incorrect,
    please update it at this time
  • When finished with the survey, click the "Submit" button at the bottom of the page.
Registration ID * 
Professional designation * 
First name * 
Last name * 
E-mail address  
Confirm E-mail address  
Institution or practice name * 
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
3 *
Practice type Dermatology Pediatrics
4 *
Primary specialty General dermatology Dermatology or Mohs surgeon
  Cosmetic dermatology Pediatric dermatology
  General pediatrics
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
Check this box if you no longer wish to receive samples of Eucerin and Aquaphor from Beiersdorf, Inc.
* Required field
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