Oak Park Family Dental Care

	Care · Comfort · Concern
	F a m i l y D e n t a l C a r e

Please answer the following questions, and help us better understand your needs and desires concerning your unique smile.

In filling out this form you will automatically be entered into our drawing. And if you qualify, you could win a dinner for two at one of these fine local restaurants. Applebee's - Marie Calendar's - Red Robin - McGrath's

Personal Information -- Please include your phone number so we can contact you if we have trouble reaching you by email. Fields marked with an asterisk* are required to process this form.

*First:		*E-Mail:
*Last:		Phone:
Street:
City:		Zip:

1) How valuable is your smile to you?
(on a scale of 1-5, with 1 being the least, how valuable is a good
smile to you and your life?)

1 2 3 4 5

2) How do you rate your smile? (5 being perfect)

	1 2 3 4 5
Color -
Shape -
Appearance -

3) If you could take a magic wand and change anything about your smile,
what would you change?

4) Please select the statement that best describes your feelings:

	I only come to the dentist when something hurts or is broken, and I just want it fixed.
	I intend to keep up-to-date on my periodic hygiene visits so I can keep my own teeth for life.
	I want more than just a healthy smile. I want to have the best looking smile I can have.

5) To what degree does cost influence your decision regarding dental care?

	Cost is the most important issue deciding when and where I have dental care done.
	I only want services that my insurance covers.
	I watch the price, but I also want to be sure that I have high quality, state-of-the-art dental care.
	I think a good smile is worth whatever it takes to feel and look my best.

6) How much time per day do you spend taking care of your teeth and gums?

	Less than one minute.
	2 minutes.
	5 or more minutes.

7) Are you interested in any of the following:

	Saving money by following a preventative dental care plan.
	Maximizing your insurance benefits by using all the coverage you are allowed.
	Paying for dental care with pretax dollars through an IRS approved program through your employer.
	Using a 12-month interest-free financing plan (on approved credit).
	Budgeting for dental care with a free automatic savings plan.

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Thank you for taking our survey. We appreciate your time and effort.
Qualified winners of our monthly dinner for two drawing will be
notified by e-mail between the 1st and 10th of the month.

To qualify for our drawing applicants must meet the following requirements;
Living in the Salem metropolitan area, One survey per household, Participants must be at lest 18 years old to enter, An individual/household can enter only once. An individual/household can win only once. Any questions? Call 503-588-3144.

Oak Park Family Dental Care · 4175 Silverton Rd. NE · Salem, OR 97305
(503) 588-7800 · fax (503) 391-0762

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