Please complete the following form to request ACT® coupon pads for your dental practice. Coupon pads can only be shipped to addresses within the United States. Please allow 4-6 weeks for delivery.

 DDS DMD RDH MD Other
Please check one:
 The address information provided is a practice/office/business address. The practice address information provided is located at a residential address. The address information provided is a residential address. Note: Fulfillment of any future sample offers cannot be shipped to residential addresses or P.O Boxes. Practice address is preferred.
How many full-time and/or part-time dentists and hygienists work in your practice
What is your primary reason for recommending a fluoride rinse? *
 Based on patient needs (caries risk, alcohol-free) Based on patient age (kids, seniors) It should be part of a patient’s daily regimen I do not specifically recommend fluoride rinses
Does your office purchase OTC rinse samples? *
 Yes No
Does your office receive free OTC rinse samples? *
 Yes No
Anticavity Flouride Rinse
Patient Coupons
ACT® Brace Care™ Anticavity Fluoride Mouthwash