To receive a rebate on your prescription of Clobex^® (clobetasol propionate), please answer the following questions. By completing the survey, you will also get emails with skin care tips and the latest information about psoriasis. You must be 18 years of age or older to participate.

Note: All questions are required.

1. Which of the following statements best describes your awareness level of a condition called psoriasis, prior to today?

Please select 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, psoriasis?

Please select Yes, currently Yes, in the past 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 psoriasis

Have psoriasis, 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 psoriasis to date?

Please select Tar products Moisturizers Salicylic Acid Products Hydrocortisone Products Anthralin Products Other treatment None - Do not treat None - Do not have/Unsure if I have psoriasis

5. Please indicate your gender.

Male

Female

6. Please enter your date of birth.

MM January February March April May June July August September October November December   DD 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   YYYY 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?

Please select White/Caucasian African American Hispanic/Latino Asian American Other Prefer not to answer

8. Which Clobex^® product have you purchased? (Please select all that apply.)

Clobex® Spray, 2 oz.

Clobex® Spray, 4.25 oz.

Clobex® Shampoo

Clobex® Lotion, 2 oz.

Clobex® Lotion, 4 oz.

None of the above

9. Your email address:

Please enter your mailing information below to receive your rebate check by mail.

Clobex^® is a registered trademark of Galderma Laboratories, L.P.