Free Product Questionnaire
You must be a DDS or DMD to receive a free sample.
Every question must be completed to receive your sample (select one):

  

         NITE WHITE with ACP®
         BreathRx®
         Two Cartridges of SPLASH

  1. Please provide the following contact information:

    First name   
Last name   
Middle initial 
Title   
Practice Name   
Street address   
Address (cont.)   
City   
State/Province   
Zip/Postal code  
Country   
Work Phone    - 
FAX    - 
E-mail
  2. Dentist License Number: (We can't ship the sample product without it.)


  3. Number of offices: 

  4. Number of doctors in your practice:   
  5. Specialties / Areas of Interest:

    General Practitioner    Periodontist    Pedodontist   

    Orthodontist               Endodontist

    Oral Surgeon              Prosthodontis

  6. Do you provide in-office shairside  whitening treatments? If yes, how many per month? 

    1-5    6-10    11-20    20+    None
  7. Which in-office whitening product do you use? 

  8. How satisfied are you with the results?  

  9.   How much do you charge on average for in-office tooth whitening treatments?
    Upper arch only        Lower arch only         Both arches

  10. Following the in-office procedure, do you give patients a take home tooth whitening product to complete the procedure? If yes, what take home product do you provide?    

  11.  How much do you charge on average for take-home tooth whitening treatments?  Upper arch only        Lower arch only         Both arches

  12.   Which member of your dental team usually initiates the conversation with patients about whitening treatments?
     

  13.   What is the most important characteristic you look for in selecting a composite?   

  14.   What  manufacturer's composites are you primarily using?
     

  15.   What type of curing light do You use to cure composites ?   

  16.   Which do you prefer for restoration work?     Multi-component bonding systems     Single bottle components?

      What brand are you using? 

  17.   Which practice management software are you currently using ?   
  18.   Are you considering a new practice management software system?  Yes  No

      If you are considering a change in software, why? Check your top considerations

      Y2K Compatibility             More features  
      More speed                      Poor customer service with current system
      Back office capabilities      Other

  19.   Are you interested in learning more about Direct Vision Practice Management Software? 
      Please check one.

    Please have a Direct Vision representative call to schedule a free in-office visit.
    I cannot schedule a visit now, but please send me more information on Direct Vision right away
    Not interested.
  20.   What type of impression material do you use for crown & bridge impressions?  Check all that apply.

    Standard Silicone    Polyvinyl Siloxane   Polyether
    Rubber-Based         Hydrocolloids          Polysulfides
  21.   Which brand do you currently use? 

  22.   What impression technique do you use?  Check all that apply.

    Putty Wash    Monophase    Double Mix     Other
  23.   What kind of trays do you use?  standard impression  double-bite impression
  24.   How many crown & bridge impressions do you take in one week? 

  25.   What temporary crown and bridge material do you use?  

  26.   Taking into account your current impression material and the technique you use, how would you rate the quality
      of your impressions?

    Poor   Moderate   Good   Excellent
  27.   Are you currently in the process of thinking about re-designing your office?  Yes   No
  28.   Do you currently have a patient referral system in place?  Yes  No
  29.   How often do you market the aesthetic prodedures offered in your practice?   

  30.   Do you routinely deplaque your patients tongue during the dental hygiene appointment?
    Yes   No

  31.   Do you routinely present oral malodor management during your dental or dental hygiene appointment?
    Yes   No

  32.   Do you currently administer breath control products for home use?   Yes  No

      If yes, which brand(s):  Check all that apply.™®

      Biotene®                      Enfresh™         Scope®                       Other
      BreathRx®                   Listerine             Tooth and gum tonic™
      Closys ll™ (Rowpar)     Oxifresh®           Trioral™                

  33.   If beneficial to your patients, would you merchandise/display dental related product in your office?
      Check one only.

    Definitely     Most Likely     Maybe     Most likely not     Never

  34.   Do you prescribe professional take-home fluoride products?    Yes   No

      If yes, how do you administer the products?  Check one only.     In-office    Through a pharmacy

  35.   Would you be interested in a free inoffice training program to provide a more Patient Centered Approach to dental hygiene/prevention and increase your revenue per patient?

    Yes   No

  36. During a preventive appointment, do you perform a prophylaxis to approximately: Check one only.

    Every patient

    75% of your patients

    50% of your patients

    25% of your patients

    None of your patients

  37.   What would be most important to you when selecting a "Live-Patient" hands-on training course? Check the most important items
    .

    Course Content                               Number of Credits

    Staff Program                                  Participating Labs

    Cost                                               Professional Growth

    Instructors                                       Increasing Profitability

    Graduate Referrals/Testimonials        Increasing Staff Teamwork

    Facilities/Location                            Guest Lecturers