Clear Form
Email Address (please do not use a shared email) *
First Name *
Last Name *
Company Name
Country * Select...UNITED STATESCANADAAFGHANISTANALBANIAALGERIAANDORRAANGOLAANGUILLAANTARCTICAANTIGUAARGENTINAARMENIAARUBAASCENSION ISAUSTRALIAAUSTRIAAZERBAIJANBAHAMASBAHRAINBANGLADESHBARBADOSBELARUSBELGIUMBELIZEBENINBERMUDABHUTANBOLIVIABOSNIA-HERZEGOVINABOTSWANABRAZILBRITISH INDIAN OCEAN TERRITORYBRITISH VIRGIN ISBRUNEIBULGARIABURKINA FASOBURUNDICAMBODIACAMEROONCAPE VERDE ISLANDSCAYMAN ISLANDSCENTRAL AFRICAN REPCHADCHILECHINACOCO ISLANDCOLOMBIACOMOROSCONGOCOOK ISLANDSCOSTA RICACROATIACUBACYPRUSCZECH REPUBLICDENMARKDJIBOUTIDOMINICADOMINICAN REPUBLICEAST TIMORECUADOREGYPTEL SALVADORERITREAESTONIAETHIOPIAFAEROE ISLANDSFALKLAND ISLANDSFIJIFINLANDFRANCEFRENCH GUIANAFRENCH POLYNESIAGABONGAMBIAGEORGIAGERMANYGHANAGIBRALTARGREECEGREENLANDGRENADAGUADELOUPEGUATEMALAGUERNSEYGUINEAGUYANAHAITIHONDURASHONG KONGHUNGARYICELANDINDIAINDONESIAIRANIRAQIRELANDISLE OF MANISRAELITALYIVORY COASTJAMAICAJAPANJORDANKAZAKHSTANKENYAKIRIBATIKUWAITKYRGYZSTANLAOSLATVIALEBANONLESOTHOLIBERIALIBYALIECHTENSTEINLITHUANIALUXEMBOURGMACAOMACEDONIAMADAGASCARMALAWIMALAYSIAMALDIVESMALIMALTAMARSHALL ISLANDSMARTINIQUEMAURITANIAMAURITIUSMAYOTTEMEXICOMICRONESIAMOLDOVAMONACOMONGOLIAMONTENEGROMONTSERRATMOROCCOMOZAMBIQUEMYANMARNAMIBIANAURUNEPALNETHERLAND ANTILLESNETHERLANDSNEW CALEDONIANEW GUINEANEW ZEALANDNICARAGUANIGERNIGERIANORTH KOREANORWAYOMANPAKISTANPALAUPALESTINEPANAMAPARAGUAYPERUPHILIPPINESPITCAIRN ISPOLANDPORTUGALQATARREUNIONROMANIARUSSIARWANDASAN MARINOSAO TOME E PRINCIPESAUDI ARABIASENEGALSERBIASEYCHELLESSIERRA LEONESINGAPORESLOVAK REPUBLICSLOVENIASOLOMON ISLANDSSOMALIASOUTH AFRICASOUTH KOREASPAINSRI LANKAST CROIXST KITTSST LUCIAST MARTINST PIERREST VINCENTSUDANSURINAMESWAZILANDSWEDENSWITZERLANDSYRIATAIWANTAJIKISTANTANZANIATHAILANDTOGOTONGATRINIDAD AND TOBAGOTUNISIATURKEYTURKMENISTANTURKS ISLANDTUVALUUGANDAUKRAINEUNITED ARAB EMIRATESUNITED KINGDOMURUGUAYUZBEKISTANVANUATUVATICAN CITYVENEZUELAVIETNAMWALLIS ISLANDWESTERN SAHARAWESTERN SAMOAYEMENZAIREZAMBIAZIMBABWE
State/Province * Select...ALABAMAALASKAARIZONAARKANSASCALIFORNIACOLORADOCONNECTICUTDELAWAREDISTRICT OF COLUMBIAFLORIDAGEORGIAHAWAIIIDAHOILLINOISINDIANAIOWAKANSASKENTUCKYLOUISIANAMAINEMARYLANDMASSACHUSETTSMICHIGANMINNESOTAMISSISSIPPIMISSOURIMONTANANEBRASKANEVADANEW HAMPSHIRENEW JERSEYNEW MEXICONEW YORKNORTH CAROLINANORTH DAKOTAOHIOOKLAHOMAOREGONPENNSYLVANIARHODE ISLANDSOUTH CAROLINASOUTH DAKOTATENNESSEETEXASUTAHVERMONTVIRGIN ISLANDSVIRGINIAWASHINGTONWEST VIRGINIAWISCONSINWYOMINGAmerican SamoaGuamMicronesia (Federated States of)Puerto RicoU.S. Minor Outlying IslandsNORTHERN MARIANA ISLANDSArmed Forces AfricaArmed Forces Americas AA (except Canada)Armed Forces CanadaArmed Forces Europe AEArmed Forces Middle East AEArmed Forces Pacific APALBERTANOVA SCOTIABRITISH COLUMBIAONTARIOMANITOBAPRINCE EDWARD ISLANDNEW BRUNSWICKQUEBECNEWFOUNDLANDSASKATCHEWANNORTHWEST TERRITORIESYUKON TERRITORYNUNAVUTFOREIGN
Phone Number
Which of the following best describes your primary job title/occupation? * Select...RDHStudentDentistOffice ManagerDental AssistantOther
Please indicate which of the following best describes where you practice dental hygiene: * Select...Private PracticeSmall Group PracticeDSO (Dental Service Organization)StudentSelf-employedAcademiaOther
What year were you first licensed in? *
What type of dentist do you practice for? * Select...GeneralOrthodontistPublic HealthPeriodontistPediatricOther