Fill in the information below to receive your free EZ-View^® Open Window Mounts Variety Pack

Title:	Dentist Assistant Hygienist Office Manager Other
First_Name:
Last_Name:
Address:
City:
State:	Zip:
Country:
	Office Phone Number:
	Alternate Phone Number:
Email:

Type of Office: General Practice Endodontic Periodontic Orthodontic Pedo Other What brand(s) of media are you currently using? (Click all that apply) Kodak Dental Film Agfa Dental Film Flow X-Ray Film Dealer Brand Other What type(s) of Radiography Holder are you using? (Click all that apply) XCP® Film Holding Instruments (Dentsply Rinn) Snap-A-Ray® Film Holder (Dentsply Rinn) Endo-Ray II® Film Holder (Dentsply Rinn) Uni-Bite® Film Holder (Dentsply Rinn) VIP Film Holder (Dentsply Rinn) Stabe® Bite Blocks (Dentsply Rinn) Uni-Grip® Universal Disposable Radiography Holders (Dentsply Rinn) RAPD™ Positioning System (Flow X-Ray Corp) Super Bite® Positioning System (Pinnacle) Kwik-Bite® Positioning System (Pinnacle) Phosphor-Ray™ Positioning for Phosphor Plate (Steri-Shield) Dealer Brand Disposable Bitewing Tabs Other What brands of film mounts do you currently use? (Click all that apply) Rinn Eezeemount® Paperboard Rinn EZ-Tab® Plastic Tab Rinn TransView® Plastic Die-Cut Rinn EZ-View® Clear Pocket Rinn EZ-View® Masked Pocket Dealer Brand Cardboard (fill in dealer name) Dealer Brand Tab (fill in dealer name) Dealer Brand Translucent Plastic Die Cut (fill in dealer name) Other What configurations of film mounts do you currently use? (Click all that apply) 1H #2 2H #2 4H #2 10 Bitewing #2 20 Bitewing #2 8H 6V 4BW #2 FMX Other FMX Other Configuration Do you plan to invest in digital X-Ray? Digital Sensor or Phosphor Plate? Yes, within 12 months Yes, within 18 - 24 months Yes, within 24 - 36 months No How did you hear about this offer? Yes, I am interested in receiving promotional coupons and offers Yes, I am interested in being part of the Rinnovators team. I would like to be contacted to provide new product testing and important survey feedback information.