NuStar

Name/Degree (*)   Telephone (*)
Practice Location   Fax
Address1 (*)   Email (*)
Address2   Do you currently lecture?
City/State/Zip (*)   How many times/year?

Please tell us if you are affiliated with any dental manufacturers.



Thank you for agreeing to serve on the panel of product evaluators for Integrated Media Solutions. At the end of the 4-week in-office evaluation, you will complete an evaluation form at our password-protected website. If you are reviewing a consumable product, you will be able to keep it. Larger products (such as radiography equipment, lasers, intraoral cameras, etc) should be returned to Integrated Media Solutions. The shipping costs will be covered by Integrated Media Solutions.



To ensure that you are asked to evaluate products appropriate to your practice and patient demographic, please check the categories below that represent your primary areas of interest. You must choose a minimum of one area of interest.

 Adhesives  Air handpieces  Antimicrobials  Burs
 CAD/CAM  Caries detection  Cements  Ceramics
 Composites  Crown lengthening  Curing lights  Diagnostics
 Digital radiography  Electric handpieces  Endodontics  Glass ionomers
 Implants  Impression material  Indirect restorations  Infection control
 Instruments  Instrument sharpening  Intraoral cameras  Lasers
 Materials  Microscopes  Office furniture  Oral cancer detection
 Orthodontics  Patient education software  Periodontics  Pharmacology
 Prosthodontics  Radiography  Removable prosthodontics  Restorative dentistry
 Sealants  Self-etch resins  Veneers  Whitening
 Other(please specify) 

 

Short Bio      
Dental School Brief Career Highlights
Year Graduated
Specialty
Number of Operatories
   
Please tell us which 3 distributors you order from most?
       

 

If you own any of the following products, please complete the information below:
Digital radiography Office furniture  
Manufacturer: Manufacturer:
Product name: Product name:
Year purchased: Year purchased:
       
Laser Microscopes  
Manufacturer: Manufacturer:
Product name: Product name:
Year purchased: Year purchased:
       
CAD/CAM Curing lights  
Manufacturer: Manufacturer:
Product name: Product name:
Year purchased: Year purchased:
       
Diagnostic equipment Intraoral cameras  
Manufacturer: Manufacturer:
Product name: Product name:
Year purchased: Year purchased: