LISTERINE® ProfessionalRegistration Form If you would like to receive free samples or speak to one of our dedicated representatives,please complete the form below We will use the information provided below to send you promotional communications from the LISTERINE® brand and invitations for research studies in accordance with our Privacy PolicyYou also have the opportunity to request a call back from one of our representatives (to find out more about our products) and/or sign up to receive samples of LISTERINE®.You may withdraw your consent at any time. Please read and select the appropriate opt in below. First Name * Last Name * GDC * Email Address * Job Title * Dentist Dental Hygientist Dental Nurse Dental Therapist I agree to being contacted by email by the LISTERINE® brand to receive updates on oral care and mouthwash topics I agree to being contacted by email by the LISTERINE® brand to receive updates on oral care and mouthwash relevant topics I agree to being contacted by email to participate in anonymous research studies on behalf of the LISTERINE® brand I agree to being contacted by email to participate in anonymous research studies on behalf of the LISTERINE® brand I agree to be contacted by a Listerine representative using the contact telephone number above (to find out more about our products) I would like to participate in the Habit Change Challenge™ (personal trial program) and receive product samples from the LISTERINE® brand via post and receive email communication about the challenge. Sample Wanted * LISTERINE® Total Care LISTERINE® Total Care Zero Practice Name * Address 1 * Address 2 Town * Postcode * I accept the Terms and Conditions and agree that the information provided will be governed by our Privacy Policy* I accept the Terms and Conditions. The Promoter reserves all rights to verify all sign ups including but not limited to asking for address and identity details (which must be provided within 14 days). The Promoter may refuse further participation in the programme where there are reasonable grounds to believe there has been a breach of these terms and conditions. Contact telephone number * Preferred time of day to call: (we aim to call you within 3 working days) : Type: Sample Form
