Nicoderm CQ


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Note: A password allows you to take full advantage of tools that can help you quit on NicoDermCQ.com, as well as special web-based offers and incentives from NicoDerm CQ and other GSK products.

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	I certify that I am 18 or older. I understand that the sample I am receiving is non-medicated and that I will receive a $7 coupon to try the real NicoDerm CQ patch with therapeutic nicotine.

Please answer the following questions so that we may better serve you. Your response is required to receive this sample.

Have you tried to quit smoking before? Yes No If you answered "yes," what method(s) did you use? (Choose as many as apply) Cold turkey Gradual reduction Nicotine gum Nicotine lozenge Nicotine patch Pill Other How likely are you to make a serious quit attempt using NicoDerm CQ? Very likely Somewhat likely Somewhat unlikely Very unlikely Not sure If you knew that wearing the patch every day for the first 21 days would triple your chances of success, how likely would you be to choose NicoDerm CQ? Very likely Somewhat likely Somewhat unlikely Very unlikely Not sure
By submitting this form you are giving GlaxoSmithKline Consumer Healthcare permission to provide you with health information, promotional offers, relevant product news and surveys that request your feedback. In the future if you do not wish to receive this information, you will be given the opportunity to opt-out. Please click here to read our Privacy Statement.

Please allow 4-6 weeks for delivery. Available to U.S. Residents only. Limit one sample per household. You must be 18 or older to receive this sample.

You will receive: A non-medicated sample patch to show you how easy and discreet it is to wear A $7 coupon to try the real NicoDerm CQ patch with therapeutic nicotine A series of emails with tips and information to help you quit

NicoDerm® CQ® See why millions of smokers have become smoke-free with NicoDerm CQ