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How Do You Live Inspired Form
ADHA Admin
2019-05-03T14:36:17-05:00
How Do You Live Inspired Form
Note:
*
= Required
Please enable JavaScript in your browser to complete this form.
Name
*
Email Address
*
Phone Number
*
Are you an ADHA member? If so, how long have you been a member?
Have you heard of Premier Dental?
*
Yes
No
Have you used any of Premier Dental’s products? If so, which have you used?
e.g. Enamel Pro Prophy Paste, Enamelon, PremierAir instruments, BioCoat sealant, Enamel Pro Varnish, 2pro Disposable Prophy Angles, etc.
What brand/type of handpiece are you currently using?
*
Do you have experience/are you comfortable being on camera?
Yes
No
Which dates are you attending ADHA 2019?
*
Friday, June 21
Saturday, June 22
Sunday, June 23
Which opportunities are you interested in participating in?
*
Product Testimonials
Product Demonstrations
Message
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