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* 1. Dentist First and Last Name

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* 2. Office Name (Please note: for dentists with multiple practice locations, supplies will be sent to one location)

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* 3. Shipping Address (No P.O. Boxes)

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* 4. City

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* 5. State

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* 6. Zip

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* 7. County

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* 8. Phone Number (with area code)

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* 9. Email address to notify your office when toothbrushes are shipped (note: this may differ from the email used for Delta Dental of Iowa or DWP dental benefits communications).

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* 10. In-kind toothbrush donations require a dental education and/or dental screening component. In the box below, please describe the community event or engagement activity where you will educate children on oral health.

Note: We are unable to donate toothbrushes for in-office patient appointments, parades, overseas mission trips, or activities that do not include a dental education component.

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* 11. Date(s) and location(s) of proposed outreach activity.

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