Dr. Smiles Pop & Prime Pen
RequiredRequired Question(s)
Required 1.
How important is a nice smile for you to make a good first impression?

very important
somewhat
not very important
not important at all
Required 2.
How do you feel about the appearance of your smile?
very good
somewhat good
indifferent
somewhat poorly
very poorly
Required 3.
Have you ever had your teeth whitened before?
Yes, by a professional
Yes, with a home whitening kit
Yes, both a and b
no
4.
If yes, what motivated you? (Check all that apply)
a special event such as a wedding or job interview
to boost your confidence and self-esteem
to stand out more
to make a positive first impression on others
Other  
Required 5.
Which of the following treatments have you used? (Check all that apply)


I have not used whitening treatments before
Crest white strips
Whitening toothpaste
Whitening oral rinse
Zoom
Opalescence
Other  
Required 6.
How did you feel about the results of your teeth-whitening?   


very pleased
somewhat pleased
not very pleased
not pleased at all
I have not used whitening treatments before
7.
If yes, did you experience any sensitivity or discomfort during teeth whitening?


Yes
No
DR. SMILES POP & PRIME PEN QUESTIONS:
 
Required 8.
How many days have you been using the Dr. Smiles Pop and Prime Pen for this survey?

 

50 characters left.
Required 9.
How often per day?


once
twice
three times
more than three times
Required 10.
When do you use your Dr. Smiles Pop and Prime Pen? (Check all that apply)
after coffee
after wine
after pizza or food with color
before going out at night
Other  
Required 11.
Do you use it more in the AM, PM or BOTH evenly?
AM
PM
BOTH evenly
Required 12.
Any sensitivity?


none
minor sensitivity
some sensitivity
frequent sensitivity
Required 13.
How likely are you to buy or recommend the Dr. Smiles Pop and Prime Pen?


likely
somewhat likely
somewhat unlikely
not likely
Required 14.
What would you pay for the Dr. Smiles Pop and Prime Pen?


$12.95- $17.95
$17.95-$22.95
$22.95-$27.95
$27.95-$32.95
Required 15.
After using the Dr. Smiles Pop and Prime Pen, would you be likely to use other Dr. Smiles products?


likely
somewhat likely
somewhat unlikely
not likely
Required 16.
How convenient was it using your Dr. Smiles Pop and Prime Pen?


very convenient
partially convenient
not convenient at all
Required 17.
How likely would you recommend the Dr. Smiles Pen Pop and Prime Whitening Pen for surface staining?


likely
somewhat likely
somewhat unlikely
not likely
Required 18.
What did you think of the overall esthetics of the outside of the Dr. Smiles Pop and Prime Whitening Pen?


very good
good
fair
poor
Required 19.
What did you think of the overall taste of the Dr. Smiles Pop and Prime Whitening Pen?


very good
good
fair
poor
Required 20.
How interested would you be in receiving a stronger in-office Dr. Smiles whitening treatment by your dentist?


very interested
interested
somewhat interested
not interested
Required 21.
Please enter the information indicated below.

First Name:
Last Name:
Email Address:
emailaddress@xyz.com

Required 22.

I, the listed above, hereby grant permission for Dr. Smiles, LLC to the use of my image and likeness in the photographs supplied to the email info@drsmiles.com. I understand that the image may be copied, edited, or published in association with the marketing material for the Dr. Smiles Pop & Prime Pen. I waive the right to inspect or approve the finished product wherein my likeness appears. 


By initialing this release I understand this permission signifies that Dr. Smiles, LLC may use my supplied photographs for their website, social media, or additional marketing materials.


please initial below 

 

50 characters left.