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Polling Form (#1)

Full Name

Phone number (to schedule your complementary Dental Exam and X-Ray)

Are you on MediCare, MedicAid or AmeriHealth Insurance?

Yes

We’re sorry but we do not accept your insurance.

Please refer to your insurance for a list of providers that can help you.

Which are you most interested in learning about?

Learning more about improving the health of my mouth and teeth

Learning more about improving the cosmetics of my teeth

Which dental and oral health topics would you like to learn about the most?

Avoiding Gum Disease

Preventing/Treating Cavities

Replacing Missing Teeth

Sensitivity/Pain with Teeth

Other

Which other type of dental and oral health topic would you like to learn about?

Which teeth cosmetics topics would you like to learn more about?

Improving Color of teeth

Improving Look of teeth

Handling crowding of teeth

Improving comfort of chewing when eating food

Other

Which other type of teeth cosmetics topic would you like to learn about?

Anything else you would like to add about understanding dentistry or oral health? (optional)

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