RAFFLE ENTRY FORM 2023

Raffle Entry Form

We will be doing a LIVE Facebook drawing on Tuesday, December 5, 2023 at 12:00 PM. You do not need to be online to win. We will notify winners. Prizes must be picked up in our office. The following form must be completed for each entry. One form for each entry. See official rules here.

Parent or Legal Guardian Name*

First NameLast Name

Patient Name*

First NameLast Name

Phone Number*

Area CodePhone Number

Email

example@example.com

Today's Date*

Date

Type of Entry*

If you posted, tagged or followed us on social media, please specify which platform and the username used. If you referred a friend, please include the friend's name. Please note, this entry is only valid if the friend is seen before the raffle deadline of 12/4/2023.*