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Commercialism Questionaire PDF Print E-mail
Friday, 13 July 2007
Commercialism/Promotional Questionnaire


Commercialism/Promotional Questionnaire

#1 Are you or any member of your immediate family currently employed either full time or part time by a dental manufacturer or any organization that sells or distributes dental products?

Yes
No

#2 Do you or any member of your immediate family receive any support or remuneration from any dental manufacturer?

Yes
No

#3 Have you or any member of your immediate family been associated in any way or received support at any time from a dental manufacturer?
Yes
No

#4 Is any organization or manufacturer supplying you with any remuneration, product or equipment in consideration for your presentation for DDS-Online?
Yes
No


#5 Do you endorse any particular products, manufacturers, laboratories or dental suppliers in the context of your presentation?

Yes
No


#6 Is any organization, manufacturer or dental group supplying you with any expense money for this presentation other than DDS-Online?

Yes
No


    INFORMATION FORM

    Please Check As Applicable:

      Dr. Mr. Mrs. Miss Ms.

      D.D.S. D.M.D. R.D.H. R.D.A. C.D.A.

    Full Name:
    Street Address:
    City: State:
    Zip: Country:

    Daytime Phone: Fax:
    E-mail Address:


    Signature (If not E-mailed):

Last Updated ( Tuesday, 18 March 2008 )