Dermal Therapy samples and information request form

Physicians
Name
Clinic Name
Street Address
 
City / Town
Province
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 #

 

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 300 samples and 100 sheets per clinic
Allow 4-6 weeks for delivery

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.

Internal Use Only

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.

Thank you for your interest in Dermal Therapy.