Max-i-Probe Irrigation Probe Sample Order Form


Title: Dentist Assistant
Hygienist Office Manager
Other
First Name:
Last Name:
Dental Office Name:
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Type of Office: General Practice Endodontic Periodontic Orthodontic Pedo
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What brand(s) of irrigating probes are you currently using? (Click all that apply)
Max-i-Probe
Luer-Lok
Monoject
VistaProbe
Dealer Brand
Other

How many irrigating probes do you use a week?

What irrigating solution are you currently using? (Click all that apply)
Sodium Hypochlorite purchased from dealer
Chlorox bleach
2% Chlorohexidine Solution (CHX)
Dealer Brand Irrigating solution
Other

How interested would you be in changing brands of irrigating solution if it would save you money? (check one)







If a new irrigating solution was proven to be more effective AND safer to use than sodium hypochlorite, how much would you expect to pay for a 16oz bottle?
Less than $10.00
$10.00 to $20.00
$21.00 to $30.00
$31.00 to $40.00
More than $41.00

Who do you buy your dental supplies from?


How did you hear about this site?


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.