We would like to invite you to participate as a speaker on the Functional Oral and Airway Health Summit-2, airing in August 2018 and hosted by Healthy Mouth Media.

In order to keep track of the myriad details involved in hosting and producing a Summit, we require all speakers to complete the following 3 items.  

1.  Please provide us with the requested information below regarding your contact information and your proposed Expert Interview.

2.  Please review and digitally sign this Speaker Form at the end.

3.  If you have an email list that you contact regularly, you will probably want to be an Affiliate of the Summit so that you can earn commissions (50%) on sales you make to your audience.  If so, please click the link at the end of this form and go to our Affiliate sign up page.  Then read the Affiliate agreement and "check" the box that you have read and agree to it.  

Best regards,

Scott Saunders, DDS and Bonnie Benjamin
Healthy Mouth Media

* 1. First and last name as you wish it to appear in the Summit (what degrees to show, etc.)

* 2. Company name (if any)

* 3. Your website

* 4. Will you have a specific landing page on your website for Summit attendees who want more information from you?
Please note:  this cannot be a sales page.

* 5. Best phone by which to reach you.

* 6. Contact information