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Product Issue Form

We are sorry to hear about any dissatisfaction you may have had with our products. In order to help us provide the best Orajel^® products we can, please take a moment to answer a few questions.

Fields marked with asterisks (*) are required.

* Incident Date:

* First Name:

* Last Name:

* Address:

* City:

* State:

* Zip:

* Country:

* Phone:

* E-mail:

Existing Medical Conditions

* Asthma:

Yes No Decline to Answer

* Diabetes:

Yes No Decline to Answer

* Eczema:

Yes No Decline to Answer

* Glaucoma:

Yes No Decline to Answer

* Heart Disease:

Yes No Decline to Answer

* Melanoma:

Yes No Decline to Answer

* Currently Pregnant:

Yes No Decline to Answer

* Psoriasis:

Yes No Decline to Answer

* Other:

Yes No Decline to Answer

If you answered Yes to any of the questions above, please specify:

Product Information

* Product Name:

* Quantity:

* Product Number:

Don't know

* Lot Number:

Don't know

* UPC Code:

Don't know

(If you answered "Don't know" to any of the above, we will be required to
follow up with you for more information.)

* Purchase Price:

* Do you have a receipt for the product?

Yes No

* Please explain the complaint thoroughly:

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If you checked the box above, please indicate which products you are most interested in:

Orajel Adult
Orajel Toddler
Baby Orajel

Orajel respects your privacy. Our goal is to use this information to improve our understanding of your interests and concerns as well as to improve our products and services. We will not sell your personally identifiable information to a third party.

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