Dental / Dental Hygiene Academic
Community Outreach Product Request Form
Thank you for contacting us regarding your upcoming community outreach event. We recognize that your planned outreach has the potential to improve the oral health of many individuals. Colgate has generously allocated products to support community outreach projects.
Requests will be considered for community outreach projects which involve dental and/or dental hygiene students providing oral health education. The projects must be approved by your school and have a faculty contact.
To assist with your project, please visit our on-line resources
· www.colgateprofessional.com – access to patient education material
· www.colgatebsbf.com - Colgate Bright Smiles Bright Futures® website: resources for oral health educators, young children, teachers and parents
To submit a request for consideration, please complete the top section of the following form. Submit the form via email attachment to the Academic Relations Manager for your area. Requests must be submitted a minimum of six weeks prior to the project date. Please allow five business days to receive a response to your request.
Name: Date of Request:Email: Phone:
If group project, additional names:
Select One: Student Faculty Other:
Select One: Dental School Dental Hygiene School Other:
Name of School:
If student, please provide faculty advisor contact information
Name: Title:
Email: Phone:
Brief summary of project, including project date and number of participants:
Products Requested:
Shipping Address (must be shipped to faculty at dental / dental hygiene school):
To be completed by Academic Relations Manager:
Name: Date of Response:
Response:
Please note that we will do our best to support as many requests as possible, but our supplies are limited and at times we may not have the specific requested materials. In an effort to be “green”, we may send imperfectly imprinted adult toothbrushes (e.g. toothbrushes returned by dental offices due to incorrect imprinting, but otherwise in perfect condition and in sealed packages), for your event.