Product Feedback Card

Date:

Treatment Facility

Name:

First

Last

Mailing Address:

City

State/Province

Zip/Postal

Country

Email Address:

Phone #:

Cancer Type and Affected Areas:

Types of Treatment You Received:

Targeted:

Immuno:

Chemo:

Radiation Therapy:

 Can you tell us the particular skin reactions you experienced and how our product helped?

 How has our product helped?

 What Did You Like About The Cream?

 Is there Anything We Can Improve?

ALOEmoist Product Feedback Card