Wufoo
CankerMelts Free Sample Questionnaire
Please take a few moments to complete this survey. ("*" denotes a required field)
Only one sample per household, we will only ship to U.S. addresses. Please allow 2-3 weeks for delivery.
We respect your privacy. We will never sell your information to another company. Information collected is used for our marketing purposes only and will be kept confidential.
A valid email address is required for verification purposes. We will send you an email to confirm your request for a sample.
Name
*
First
Last
Address
*
Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
United States
United Kingdom
Australia
Canada
France
New Zealand
India
Brazil
----
Afghanistan
Åland Islands
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua & Barbuda
Argentina
Armenia
Aruba
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia & Herzegovina
Botswana
Bouvet Island
British Indian Ocean Territory
British Virgin Islands
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Cape Verde
Caribbean Netherlands
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo - Brazzaville
Congo - Kinshasa
Cook Islands
Costa Rica
Côte d’Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czechia
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard & McDonald Islands
Honduras
Hong Kong SAR China
Hungary
Iceland
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau SAR China
Republic of North Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar (Burma)
Namibia
Nauru
Nepal
Netherlands
New Caledonia
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestinian Territories
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Réunion
Romania
Russia
Rwanda
Samoa
San Marino
São Tomé & Príncipe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia & South Sandwich Islands
South Korea
South Sudan
Spain
Sri Lanka
St. Barthélemy
St. Helena
St. Kitts & Nevis
St. Lucia
St. Martin
St. Pierre & Miquelon
St. Vincent & Grenadines
Sudan
Suriname
Svalbard & Jan Mayen
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad & Tobago
Tunisia
Turkey
Turkmenistan
Turks & Caicos Islands
Tuvalu
U.S. Outlying Islands
U.S. Virgin Islands
Uganda
Ukraine
United Arab Emirates
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Wallis & Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Country
Email
*
Phone Number
###
-
###
-
####
When you get a canker sore which product(s) do you currently use to treat it?
*
Kank-A
Canker Cover
Orabase
Orajel
Anbesol
Canker-X
Gly-Oxide
Other
check all that apply
If you selected "Other" in the previous question, please specify:
*
If you didn't select "other", please enter "N/A"
How often do you typically get canker sores?
*
More than once a month
Once a month
Once every couple of months
Once or twice a year
How often do you get a canker sore and let it go untreated?
*
Never
0-25% of the time
25-75% of the time
75-100% of the time
Where do you buy your oral care products?
*
Rite Aid
Walgreens
Other
If you selected "other" in the previous question, please specify where:
*
If you didn't select "other", please enter "N/A"
If you selected "other", would you redeem a coupon for free product within 7 days of receiving it at:
*
Rite Aid
Walgreens
Neither
When choosing which product to buy for treating your canker sores, which of the following most influences your decision?
*
Price
Packaging
Natural ingredients
Pain relief
Speed of healing
Which of the following promotions would you prefer?
*
$1-Off Coupon (in-store discount)
Buy-1-Get-1-Free Rebate (mail-in rebate)
When selecting a product, how important is it to you that the products are all-natural?
*
Not important at all
Somewhat important
Very important
Do you ever get a canker sore on the dry part of your lip?
*
- select one -
Yes
No
Have you used CankerMelts before?
*
Yes
No
- select one -
Please select your age group:
*
- select one -
Under 18
18-24
25-34
35-54
55+
Please select your gender:
*
- select one -
Male
Female
Do Not Fill This Out
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