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Registration

A few times per year we have special promotions and product offers. If you would like to receive them, please complete the questions below and provide us with the required personal information. Offers are limited to one per practice and valid for redemption by licensed dentists, registered dental hygienists and licensed medical professionals only.

 

Title*   

 

 

 

 

 

 

 

 

 

 

 
 

Is yours a private practice?


 

What type?






 

What dentifrice do you personally use most often? (please be specific)

 

What dentifrice does your practice recommend and sample most often to patients? (please be specific)

For adults:

For kids/teens:

 

What power toothbrush do you personally use most often? (please be specific)

 

What power toothbrush does your practice recommend and sample most often to patients?
(please be specific)

For adults:

For kids/teens:

 

 

Safety Notice: Please remember to replace your brush head after 3 months of use, or if the brush is damaged, or if parts become loose. Extended usage, loose parts or excessive wear could lead to brush head breakage, generation of small parts and possible choking hazard. Inspect brush for loose parts before use.