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Patient's First Name
Patient's Last Name
Email
Phone Number
Do patient’s gums bleed when brushing
yes
No
How many times per day are patient’s teeth being brushed
Patient's teeth are not brush daily
Patient's teeth brushed once daily
Patient's teeth brushed 2 or more times daily
Does the patient brush/floss their own teeth?
Yes
No
What is the biggest perceived challenge to daily oral hygiene care?
Lack of time
Cooperation of patient
Brushing is painful to patient
Lack of oral care products
Other
Has a dental professional previously demonstrated or discussed with you ways to improve ease of oral care?
Yes
No
Going to the dentist for regularly scheduled visits is very important to total bodyhealth.
I strongly agree
I somewhat agree
I somewhat disagree
I strongly disagree
Are you aware of the benefits of the Triple Bristle Toothbrush?
yes
No
What is a triple bristle toothbrush?
Are you aware that bleeding gums can be a sign of periodontal problems that can affect your overall health?
Yes, I am aware
No, but I would like to know more
I don't find this to be important to my overall health
By signing, I agree to enroll the above named individual in the UCP Healthy Smiles Program and agree to watching dental educational videos.
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