Toothpaste Test Application

Toothpaste Test Patient Form

Hi Super Friends, we will mail you the instructions, toothpaste sample in your child's requested flavor and survey. You should receive the toothpaste and survey by 6/14 and can start as soon as you receive it.

First Name*
Last Name*
Address*
We will be mailing you the survey and sample. Please provide your complete address, apartment #, city, state, zip.
Email*
Child's Name and Age*
(Ex. Moler, 7; Swish, 9) If we don't have this info, we can't include you.
What flavor does your child prefer?*
We want your child to test the toothpaste flavor they like best.
Office*
Please select the office you normally go to.
Toothpaste Test Waiver & Release*
Thanks for participating in our Toothpaste Test! The ingredients in the toothpaste are safe and have been formulated especially for children. Please take a minute to review the following information about allergies and ingredients, then sign your child(ren)’s names, your name and the date.
- I acknowledge that my child(ren) named below does/do not have any food allergies
waiver 2*
- I acknowledge that the Toothpaste is formulated for human children and must not be given to dogs (it contains xylitol). Xylitol is a sweetener that is safe for people but can cause severe health issues if consumed by dogs.
Waiver 3*
- First Choice
Waiver 4*
- First Choice
Waiver 4*
- First Choice
Waiver 4*
- First Choice
Waiver 4*
- First Choice
Waiver 4*
- First Choice

Toothpaste Test Application was last modified: May 18th, 2021 by The Super Dentists

Toothpaste Test Application

Toothpaste Test Patient Form

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