Dermal Therapy samples and information request form

Chiropodists
Name
Clinic Name
Street Address
City / Town
Province	Choose BC AB SK MB ON QC NB NS NL PE NW YU NU
Postal Code	Please do not use dashes or spaces
E-mail
Telephone #	Please do not use dashes or spaces
FAX #	Please do not use dashes or spaces
License #

In order to receive your samples, legally, you must answer 2 questions. You will be credited one penny for your response and it will be applied as payment for your samples OR you can request to receive the penny, please indicate below.

How did you hear of Dermal Therapy?

Would you recommend Dermal Therapy? Choose Yes No Unsure

I would like to receive a penny for my participation. (Unfortunately no samples will be provided.)

We have the following Dermal Therapy information and samples we can send for your patients. Please choose the items you would like us to send:

	Dermal Therapy brochures with $2.00 coupon. 50 brochures will be sent to you		Heel Care 2 grams, 100 samples

Note: Limit of 150 samples and 50 sheets per clinic
Allow 4-6 weeks for delivery

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If you are holding an event, please provide the following information

 

Event Name
Event Date (DD-MM-YY)
Event Description
Number of Participants

Please add any other comments or information we may need here. (100 Characters Max)

Be sure to include your clinic name, address and phone number as you will be required to sign a formal request form before the samples are shipped.

	We feel so confident in the quality of our product that if your patient purchases a Dermal Therapy product and is not satisfied, they can return it for their money back.
	Internal Use Only

Thank you for your interest in Dermal Therapy.