Tell us what you think and receive $15 off your next prescription purchase of Clindagel® (clindamycin phosphate gel) topical gel, 1%. You can get a rebate on your purchase of Clindagel® by filling out the form below. When you click "Submit," you'll be able to access a printable Clindagel® Rebate. Print out the rebate form and mail it with your printed pharmacy receipt to the address shown below to receive your check. This is a limited-time offer. You must be 13 or older to participate in our survey and obtain the rebate. Note: All questions must be answered. 1. How long ago did you first experience symptoms associated with an acne condition? Within the past month 1-3 months ago 3-6 months ago 6-12 months ago 1-3 years ago 3 years ago or longer Never - I do not have an acne condition 2. Which of the following products have you ever used specifically to treat an acne condition? (Check all that apply.)   Accutane® (isotretinoin) Capsules or generic Clindagel® (clindamycin phosphate gel) topical gel, 1% Differin® (adapalene) Gel, Cream, Solution and/or Pledgets, 0.1% Retin-A® (tretinoin) or generic Other prescription product Other over-the-counter product None - I do not treat my acne condition None - I do not have an acne condition 3. In a typical treatment cycle, how many times do you treat your acne condition with medication?   More often than once a day Once a day Several times a week Once a week Several times a month Once a month Less often than monthly Only as needed to treat my condition/symptoms Never - I do not treat my acne condition Never - I do not have an acne condition 4. How is your acne condition being treated?   Treated by a dermatologist Treated by a primary care physician Treated by myself with over-the-counter products None - I do not treat my acne condition None - I do not have an acne condition 5. How many times in the past 12 months have you refilled your prescription medication for your acne condition?   None - I have not refilled my prescription 1-2 times 3-4 times 5-6 times 7 or more times None - I do not use a prescription to treat my acne condition None - I do not treat my acne condition None - I do not have an acne condition Your Information Please indicate your gender.   Male Female Please select your date of birth.   Month   Day   Year Select January February March April May June July August September October November December   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   2012 2011 2010 2009 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   First name:   Last name:   Address 1:   Address 2:   City:   State: Select One Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington D.C. West Virginia Wisconsin Wyoming   Zip:   Email:     I would like to be contacted about special promotions from Clindagel® (Galderma). I would like to be contacted about future opportunities to share my opinion on products and promotions. Accutane® is a registered trademark of Roche Pharmaceuticals. Retin-A® is a registered trademark of Ortho Dermatological. Differin® and Clindagel® are registered trademarks of Galderma Laboratories, L.P.