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Max-i-Probe Irrigation Probe Sample Order Form

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 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) Very Interested Somewhat Interested Not sure Not very interested Not at all interested Other 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.