MIRACLE GRIP® SPECIAL OFFER If you would like to receive a 10 DAY SAMPLE of Miracle Grip®, please complete the information below: *First Name: *Last Name: *Address: *City: *State: *Zip: *Phone Number: (555)555-5555 *Birthday:  /  /  MM/DD/YYYY *E-mail Address: * Indicates required information 1. How long have you had dentures? Thinking about getting dentures Less than 1 year 1 year to 2 years 2 years to 5 years More than 5 years 2. What type of dentures do you have? Upper: Full Partial None Lower: Full Partial None 3. Have you used a denture adhesive in the past? Yes, I use Miracle Grip®. Yes, I use Fixodent®. Yes, I use Poligrip®. Yes, I use Seabond®. Yes, I use some other brand of adhesive. 4. If you answered "Yes" to the question #3, how long have you been using the adhesive? Less than 6 months 1 year to 2 years 2 years to 5 years More than 5 years 5. How frequently do you use the adhesive? Once per day More than once per day More than once per week Special Occasions Never Important Information Please Note: U.S. Medical Systems, Inc. takes every precaution to protect the information you provide us about your denture habits. Our company will not provide this personal information to anyone without your written approval. Occasionally, your permission may be sought to provide free Miracle Grip® samples to your or friends, sneak previews of new Miracle Grip® concepts, or personalized offers or guidelines. You may also be asked your opinion on suggestions to make Miracle Grip® a better product. In these cases, your information may be securely shared with a third party contractor working directly for U.S. Medical Systems, Inc. You can terminate any comments related to the above conditions at any time by contacting U.S. Medical. Please see U.S. Medical Systems, Inc.'s Privacy Statement for complete details.