Name of Child Patient
*
First Name
Last Name
Entry Date
*
-
Month
-
Day
Year
Date
Did we find any cavities?
*
Yes
No
Sorry... only kids who didn't have a cavity can enter this draw. But there's always next time! Be sure to take care of your teeth and brush them every night and morning so next time you can be a Cavity-Free Kid!
If I win, please contact:
*
First Name
Last Name
Contact person's phone #
*
Please enter a valid phone number.
Format: (000) 000-0000.
Submit
Cavity-Free Kids Ballot
If you had no cavities at your last checkup at our office, fill out this ballot to have a chance at winning one of our awesome monthly draws!
Should be Empty: