Safety Device Evaluation: Participation Qualifier

Thank you very much for your interest in participating in our upcoming research study.

Please provide answers to the following questions to enable us to determine whether you qualify for this study. If you fit the qualifications for this particular study, we’ll follow up with an email invitation including more details about when we’ll be sending the product and instructions for use.

Question Title

* 1. Are you currently a:

Licensed DDS/DMD

Registered Dental Hygienist

Office Assistant

Other (please specify)

Question Title

* 2. For how many years have you been working as a DDS/DMD or dental hygienist?

Less than 2 years

2 to 7 years

8 to 15 years

More than 15 years

Question Title

* 3. How many days per week do you currently practice?

One or less

Two

Three

Four

Five or more

Question Title

* 4. Do you regularly administer local anesthesia in your clinical setting?

Yes

Question Title

* 5. How many times a week do you perform local anesthesia injections?

Less than 5 times

5 to 9 times

10 to 15 times

More than 15 times

Question Title

* 6. Please provide your name, mailing address, telephone number, and email address. (*Required information)

Name* *

Company

Address* *

Address 2

City/Town* *

State/Province* *

ZIP/Postal Code* *

Country* *

Email Address* *

Phone Number