Name:

Address:

E-mail:

1. Please choose the specialty in which you practice medicine:
   • Dermatology
   • Pediatrics
   • Family Practice/General Practice
   • Internal Medicine
   • Other
2. Do you currently have a CORIA sales representative who distributes Tetrix™ Cream samples and information to your office?
   • Yes
   • No
3. How many hand eczema patients do you see weekly?
   • Fewer than 5
   • 5-10
   • 10-15
   • More than 15
4. Now that you know more about Tetrix™ Cream, is this a product that you will prescribe in the future for your hand eczema patients?
   • Yes
   • No
5. I would like to receive e-mails about Tetrix™ Cream and other products available from CORIA Laboratories, Ltd.
6.