Note: All questions are required.

1. Which of the following statements best describes your awareness level of a condition called melasma, prior to today? (Please select one.)
Had not heard of it
Heard of it, but didn't know what it was
Knew what it was

2. Have you ever had, or do you currently have, melasma?
Yes, in the past
Yes, currently
No
Do not know

3. Which of the following statements best describes your current treatment status? (Please select one.)
Do not have/Unsure if I have melasma
Have melasma, but do not treat
Treat on my own without the aid of a doctor
Consult with my doctor and treat without prescription products
Consult with my doctor and treat with prescription products

4. Which of the following treatments have you used to treat your melasma to date? (Please select all that apply.)
Alphaquin HP® 4% Cream (hydroquinone 4%)
Alustra® (hydroquinone USP 4%)
Claripel™
EpiQuin™ Micro (hydroquinone USP 4%)
Esoterica®
Glyquin-XM® Cream (hydroquinone USP 4%)
Lustra® (hydroquinone USP 4%)
Lustra AF® (hydroquinone USP 4%)
Melquin HP® 4% Cream (hydroquinone 4%)
Nuquin HP® 4% Cream (hydroquinone 4%)
Porcelana®
Tri-Luma® Cream (fluocinolone acetonide 0.01%, hydroquinone 4%, tretinoin 0.05%)
Other treatment
None - Do not treat
None - Do not have/Unsure if I have melasma

5. Please indicate your gender.

	Male
	Female

6. Please enter your date of birth.
month January February March April May June July August September October November December day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 year 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900

7. What is your race/ethnicity?
White/Caucasian
African American
Hispanic/Latino
Asian American
Other
Prefer not to answer

8. Your email address:

I would be interested in receiving special promotions about Tri-Luma® Cream or other Galderma products via email.

Please enter your mailing information below.
* Required fields if you selected to receive a rebate or a brochure.

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Zip:*

Alphaquin HP®, Melquin HP® and Nuquin HP® are registered trademarks of Stratus Pharmaceuticals, Inc.. Alustra®, Esoterica®, Lustra® and Lustra AF® are registered trademarks of Medicis Pharmaceutical Corporation. Claripel™ is a registered trademark of Stiefel Laboratories Inc. EpiQuin™ Micro is a trademark of SkinMedica. Glyquin-XM® is a registered trademark of ICN Pharmaceuticals, Inc. Tri-Luma® is a registered trademark of Galderma Laboratories, L.P.