Nominate a Dentist or Dental Assistant

In honor of National Dentist's Day and Dental Assistants Recognition Week, share an unusual, funny or special fact about your favorite dentist or dental assistant, along with their photo, and they will be entered to win one of five $50 Amazon Gift Cards. Five dentists and five dental assistants will be selected. Nominations are due March 31, 2022.

* Required

Your Information

First name: *

First name: is mandatory

Last name: *

Last name: is mandatory

Cell phone number: *

Cell phone number: is mandatory

Phone number should be numbers only, without dashes. For example: 5405555555.

Practice phone: *

Practice phone: is mandatory

Phone number should be numbers only, without dashes. For example: 5405555555.

Email: *

Email: is mandatory

Practice name: *

Practice name: is mandatory

Practice address: *

Practice address: is mandatory

* Required

City: *

City: is mandatory

State: *

Please select at least one of the items

Zip: *

Zip: is mandatory

* Required

Nominee's Information

First name: *

First name: is mandatory

Last name: *

Last name: is mandatory

Email:

Email: is mandatory

Practice name: *

Practice name: is mandatory

Practice phone: *

Practice phone: is mandatory

Phone number should be numbers only, without dashes. For example: 5405555555.

Practice address:

Practice address: is mandatory

* Required

City: *

City: is mandatory

State *

Please select at least one of the items

Zip: *

Zip: is mandatory

* Required

Are you nominating a dentist or a dental assistant? * *

Dentist

Dental Assistant

Please select at least one of the items

How do you know the person you are nominating? *

Please select at least one of the items

Tell us something unusual, funny or special about this person: *

This field is mandatory

Photo: *

Upload a photo of the person you are nominating.

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