Aquoral Dry Mouth Spray

As low as $55/Mo!

The Basics

5 minutes to complete

First Name *

Middle

Last name *

IMPORTANT: Name must match your ID
You must enter your own phone number and email address. Do not use a shared or someone else’s email or phone number.

Email *

Phone *

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General info

Gender *

Male

Female

Date of birth *

Height (feet, inches) *

Weight (pounds) *

Your Dry Mouth Symptoms

Tell Us About Your Dry Mouth *

My mouth often feels dry or sticky

I sip water or use lozenges a lot to stay comfortable

My mouth feels dry when I talk, eat, or wake up

I don’t have dry mouth symptoms right now

Select all that apply

Referring Physician

Please enter the name of your referring physician

Not required – your prescription is included with this intake.

Allergies

Do you have any allergies? (e.g., silicon dioxide, aspartame, corn) *

(or type "None")

Medical Conditions

Please list all your medical conditions *

(or type "None")

Medications and supplements

Please list all medications or supplements you currently take, the dosage, and how long you've taken them (or type "None") *

PKU Disorder

Have you ever been diagnosed with Phenylketonuria or had a negative reaction to silicon dioxide or aspartame? *

Yes