GumChucks Henry Schein Sample Request

If you are interested in receiving a sample of GumChucks, please complete this form or call us at 855-424-8257.

Practice Name or School Currently Attending*
Practice Specialty*
Number of Locations*
Number of Operatories / Chairs*
Number of Hygienists / RDAs*
Number of Patients seen weekly*
Contact Name*
First Last
Your Position*
Office Phone*
Contact Email*
Office Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Who is your preferred Distributor?*
If you do not use a preferred distributor, please write in "none"
If you order from a distributor, please enter the NAME of the Dental Distributor Rep that you order from most frequently. If this does not apply to you, please write N/A*
Which type of sample are you interested in receiving?*
We have two types of samples - one featuring our standard tip (found in our Adult ProFloss and GC Kids products) for non-braces, and the other featuring our Ortho tip (found in our ORTHOgami products) for braces. If you are interested in requesting brochures, please order them directly through our website store.
Would you like to earn a FREE Clinical CE Credit?*
We offer a free Webinar to train your team on how to introduce GumChucks to your patients. Each attendee will receive a Live CE Credit.
How did you hear about GumChucks?*