qii Ambassador Survey

Thanks for taking the time to fill out the survey! Excited for you to try some qii and be part of the communi-tea :)

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* 1. What is your full name?

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* 2. Please list your email address

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* 3. Please indicate your role in the industry below:

Dentist

Dental Assistant

Dental Hygienist

Dental Student

Dental Office Admin

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* 4. Please provide your dental details below (Dental Students skip to Q5)

Office Name

# of Dental Hygienists in the office

Dental License Number

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* 5. Please provide your education details (dental professionals skip to Q6)

Type of Program

School

Graduation Date

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* 6. Please provide all applicable social handles/online profiles

Instagram

Twitter

Personal Website

Facebook

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* 7. Please provide your shipping address where we can send samples to.

Address *

City *

State *

ZIP/Postal Code *

Phone Number

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* 8. How did you hear about qii

FB/IG

Website

Amazon

Dental Community

Other (please specify)

qii Ambassador Survey

Question Title

* 1. What is your full name?

Question Title

* 2. Please list your email address

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* 3. Please indicate your role in the industry below:

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* 4. Please provide your dental details below (Dental Students skip to Q5)

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* 5. Please provide your education details (dental professionals skip to Q6)

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* 6. Please provide all applicable social handles/online profiles

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* 7. Please provide your shipping address where we can send samples to.

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* 8. How did you hear about qii

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* 9. If approved, what name would you want as your discount code? (ex. JANETW20 or NYDENTAL20)