Professional Oralieve Sample Request

Thank you for your interest in helping patients with dry mouth.

To receive your Oralieve samples and literature, please complete the below questionnaire. Please note, it can take up to 21 days to receive your samples. If you do not receive within 28 days, please contact hello@oralieve.co.uk.

Please be aware we are unable to send Oralieve Professional samples to your home address. For UK addresses only.

Question Title

* 1. How many patients do you see on average a month with dry mouth?

1 - 5

6 - 10

11 - 15

16 - 20

21+

Question Title

* 2. What are the main factors that cause their dry mouth?

Medication side effect

Treatment for head and neck cancer

Sjogren's syndrome

Mouth breathing / snoring

Other (please specify)

Question Title

* 3. Which brand do you currently recommend for dry mouth relief?

Biotene

BioXtra

Saliveze

Oralieve

Glandosane

Other (please specify)

Question Title

* 4. How did you hear about Oralieve?

Google

Facebook

Twitter

BSDHT

RCSLT

Word of Mouth

Event (please specify in 'Other' box)

Publication (please specify in 'Other' box)

Other (please specify)

Question Title

* 5. Contact Details for Samples & Literature (please fill in BLOCK CAPITALS):

Full Name

Job Title

Department

Practice / Clinic / Hospital Name

Address

City

Postcode

Country

Email Address

Phone Number

Question Title

* 6. Please let us know if you would like to receive future communication from Oralieve

Yes, I would like to receive future communication from Oralieve

No, I would like to opt out of receiving communication from Oralieve