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Fill in the information below to receive your free Crescent® Prophy Cups or Cups & Brushes Sample Pack

Title:	Dentist Assistant Hygienist Office Manager Other
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Type of Office:	General Practice Endodontic Periodontic Orthodontic Pedo Other

What brand(s) of prophy cups are you currently using? (Click all that apply) Crescent Young Dental Water-Pik, Inc. Denticator Dealer Brand Other What type(s) of prophy cups are you using? (Click all that apply) Screw Type Soft Webbed Screw Type Firm Webbed Screw Type Soft Ribbed Screw Type Firm Ribbed Right Angle/latch type Webbed Right Angle/latch type Ribbed Snap-On Soft Webbed Snap-On Firm Webbed Screw Type Pointed Midget Soft Midget Firm Petite Turbo Turbo Plus Other Is the color of the prophy cups important? Select One Yes No Why: Is latex-free important? Select One Yes No Why: What do you place your prophy cups on when in use? Prophy Angle Handpiece Other Please select which sample pack you would like to receive: Select One Prophy Cups (2 pieces each: Screw Type Ribbed and Screw Type Webbed Cups) Variety Pack Prophy Cups and Prophy Brushes How did you hear about this offer? Yes, I am interested in receiving promotional coupons and offers Yes, I am interested in being part of the Rinnovators team. I would like to be contacted to provide new product testing and important survey feedback information.