A few times per year we have special promotions and product offers. If you would like to receive them, please complete the questions below and provide us with the required personal information.

Offers are limited to one per practice and valid for redemption by licensed dentists, registered dental hygienists and licensed medical professionals only.

*Required form selections.
Title*
First Name*
Last Name*
Practice Name*
Street Address*
City*
State*
Zip Code*
Telephone
E-mail Address*
Is your practice
What type?
If you chose "Other",
please describe your practice below.
Please Complete the Following 6 Questions

1. In the last six months, for which of the following indications have you recommended an over-the-counter product?




2. Please indicate if you are aware of the products listed below. In the last six months, have you recommended any of these products? Additionally, let us know if you would be interested in sampling any of these products to your patients.

For Children
Baby Orajel® Teething Pain Medicine
Baby Orajel® Teething Swabs
Baby Orajel® Tooth & Gum Cleanser
Orajel®Toddler Training Toothpaste
Orajel®Plaque Revealers for Kids
For Adults
Orajel® for Toothache Pain
Orajel® Mouth Sore Medicine & Rinse
Orajel® Dry Mouth Moisturizing Gel
Orajel® Tooth Desensitizer
Orajel® Anti-Bacterial Bleeding Gum Rinse

3. To which types of patients, if any, would you recommend our Orajel® Tooth Desensitizer? Please explain why.

To
Reason

4. To which types of patients, if any, would you recommend our ARM & HAMMER® Spinbrush® Pro Whitening SONIC Toothbrush? Please explain why.

To
Reason

5. To which types of patients, if any, would you recommend our ARM & HAMMER® Age Defying Toothpaste? Please explain why.

To
Reason

6. If samples of the following products were available together, at preferred professional prices, how interested would you be in purchasing them for your practice?

For Infants

Baby Orajel® Teething Swabs

Baby Orajel® Tooth & Gum Cleanser

For Children, Ages 2-4

Orajel® Toddler Training Toothpaste

ARM & HAMMER® Spinbrush® Kids Power Toothbrush

For Children, Ages 4-13

Orajel® Plaque Revealing Rinse

ARM & HAMMER® Advance White® Brilliant Sparkle® Toothpaste

ARM & HAMMER® Spinbrush® Kids Power Toothbrush

For Ortho Patients

Orajel® Mouth Sore Medicine

ARM & HAMMER® Age Defying Toothpaste

ARM & HAMMER® Spinbrush® Pro Clean SONIC Toothbrush

For Families

Orajel® Baby Tooth & Gum Cleanser

Orajel® Toddler Training Toothpaste

Orajel® Plaque Revealing Rinse

ARM & HAMMER® Advance White® Brilliant Sparkle® Toothpaste

ARM & HAMMER® Age Defying Toothpaste

ARM & HAMMER® Spinbrush® Pro Series

ARM & HAMMER® Spinbrush® Kids Power Toothbrushes

Are you interested in receiving future promotions and product offers from us?*
If you chose "Yes", please choose the brands
in which you're interested.


If you chose "No", please explain why.

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Church & Dwight Co., Inc. 2009 All rights reserved. Arm & Hammer, Spinbrush and Orajel are registered trademarks of Church & Dwight Co., Inc.

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