Perio Protect

Tray Registration

Perio Protect

Tray

Registration

Communication Approval

Please check the opt-in box below.

Demographics

Tell us a bit more about yourself.
Name(Required)
Your Location
Dentist/Prescriber's Name(Required)
Dentist/Prescriber's Location(Required)

Dental Health Information

Let's get a bit more information about where you are currently at.
Condition being treated:
Please check all that apply.
How often do you go to the dentist in a year?
Do you floss regularly?
On average, how often do you brush?

Additional Demographics

Answers are for internal marketing use only, to help us refine our marketing messages.
Your Age
Your Gender
Your Annual Salary
Your Marital Status
A woman using a Perio Tray® by Perio Protect