Sample Request

If you are interested in receiving a sample of GumChucks, please complete this form or email us at smiles@GumChucks.com. Please note that we can no longer ship to residential addresses.

Practice Name*
Practice Specialty*
# of Locations*
# of Operatory/Chairs*
# of hygienists/RDAs*
# of patients seen weekly*
Name*
First Last
Your Position*
Phone*
Email*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Do you sell hygiene products in your office?*
- Yes
- No
If not, would you consider selling products?*
- Yes
- No
Do you offer treatment plans that include dental floss?*
- Yes
- No
Who purchases the items that go in the office sample bag?*
What goes in your sample bag?*
Toothbrush, dental floss, toothpaste, etc. Please list specific brand names if possible.
How did you hear about GumChucks?*
Does your office provide ortho services?*
- Yes
- No