Qualified Leads FormDOES MY CUSTOMER QUALIFY FOR A DEMO? Name Name of Dental Practice Primary Contact at Dental Practice Email Address of Primary Contact Contact Number of Primary Contact Specialization of Primary Contact Dentist Periodontist Orthodontist Dental Hygienist Oral Health Therapist Other Does the Practice already use an EMS device? Please select their device from the options below: AIRFLOW MASTER PIEZON® AIRFLOW MASTER® PIEZON® 250 AIRFLOW® HANDY 3.0 AIRFLOW® HANDY 2+ Built in PIEZON to practice chair Practice does not use an EMS PIEZON® and/or AIRFLOW® device AIRFLOW MASTER PIEZON®AIRFLOW MASTER®PIEZON® 250AIRFLOW® HANDY 3.0AIRFLOW® HANDY 2+Built in PIEZON to practice chair Does the Practice have an interest in any of the following specializations? Implants Orthodontics Special Needs Dentistry Periodontics Pediatric Dentistry Other Is the Principal Dentist/Practice Owner willing to commit to stay for the entire demonstration (minimum 45 mins)? Yes No Is the Principal Dentist/Practice Owner ready to purchase within the next 6-12 months? Yes No Your Name Confirmation I confirm to have qualified this Dental Practice.