REQUEST MYHAPPYMOUTH TRAINING

*required

Practice and Program Information:

PRACTICE NAME*

NAME OF PRIMARY DENTIST*

NAME OF EMPLOYEE RESPONSIBLE FOR YOUR CUSTOM PROGRAM*

EMAIL OF EMPLOYEE RESPONSIBLE FOR YOUR CUSTOM PROGRAM*

COOPERATIVE ACCOUNT# (Found on Invoice. Optional)

GROUP ID#* (Group ID# for the program you need training. This ID is found on your printed cards.)

Request Training:

NAME OF PERSON REQUESTING TRAINING:*

WHAT KIND OF TRAINING CAN WE HELP YOU WITH?

What should we focus on specifically during our training time.

WHAT DAYS AND TIMES WORK BEST FOR YOU TO SCHEDULE AN ONLINE TRAINING?

We will contact you to schedule a specific date and time.

PLEASE INCLUDE THE NAME AND EMAILS OF THOSE YOU WOULD LIKE INVITED TO THE TRAINING:

Include yourself.

Once submitted, we will contact you to schedule a training.