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Company Name
   
 
 
 
Your Name
   
 
 
 
Email Address
   
 
 
 
Phone Number
   
 
 
 
What type of dentistry do you practice?
 
General Practitioner
 
Orthodontics
 
Prosthodontics
 
Oral Surgery
 
Pediatic Dentistry
 
Other
 

 
 
 
What cities/states do you practice in?
   
 
 
 
What type of marketing/sales collateral do you currently offer?
   
 
 
 
What are the top three reasons patients continue to use you?
   
 
 
 
What are the top three complaints/problems patients have with your practice?
   
 
 
 
How do you think you could use video?