DentistRx Revolation
21
Revolation
®
Registration Form
/ /
Serial number
Date of purchase
Location of purchase
Your name
Address/Address 2
City
State
Zip code
( )
Area code
Phone number
Email address
1. What kind of toothbrush were you using prior to this purchase?
o
Manual
o
Battery-Operated Toothbrush
o
Rechargeable Power Toothbrush
2. Which brand?
o
InteliSonic
o
Sonicare
o
Oral B
o
Other
3.
What factor(s) most influenced your decision to buy the Revolation?
Check all that apply.
o
Dentist Recommendation
o
Hygienist Recommendation
o
Family/Friend Recommendation
o
Retail Display/Packaging
o
Desire to improve my oral health
o
Price
o
Other
4. How will this purchase be utilized?
o
Personal Use
o
Gift
5. Please help to identify who will be using this product:
No. of users:
o
1 user
o
2 users
Sex:
o
M
o
F
Age group:
o
Under 19
o
20–34
o
35–49
o
50–64
o
65+
Thank you for completing this survey.
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