CIEOS

FREE Optica Giveaway

Complete and submit the Assessment Form to enter the drawing to be held at the Chicago Mid-Winter meeting 2005 for a free Optica Intraoral Camera. Winner will be announced at the end of the meeting and will not have to be present to receive the prize. The prize is a complete Optica Intraoral Camera System that includes camera handpiece, docking station, and video cables. Winner will be responsible for all costs associated with installation, training, and applicable taxes. Existing Cieos clients are not eligible and no purchase is required. This prize can't be combined with any other offer, is non-transferable, and there is no cash alternative. The winner will be notified in writing. Offer void where prohibited.

Contact Information
Name*
Street address*
City*
State & Zip*
Telephone & Fax*
E-mail*
Preferred method of contact	Telephone Fax Mail E-mail

Your Practice
Practice Specialty	General		Perio
	Pediatric		Oral Surgery
	Ortho		Endo
			Other

Practice Type	Solo		Multi
	Group		Clinic
			Other

Treatment Rooms	Open	Closed Bays Total

Current Operations: Do you have...
Computers?	Yes	No	How many?
Network?	Yes	No	Type
Practice Mgmt Software?	Yes	No	Name
Intraoral Camera?	Yes	No	Name
Digital Radiography?	Yes	No	Name
Digital Camera?	Yes	No	Name
Patient Education?	Yes	No	Name
Imaging Software?	Yes	No	Name
Office Messaging?	Yes	No	Name
Satellite Office(s)?	Yes	No	How many?
Remote Access?	Yes	No	Type

Tell us about your office culture
Team Style	Motivated (open to change)		Cautious (resistant to change)

Workload	Very Busy	Moderate	Slow	Inconsistent

Environment	Stressful	Comfortable	Relaxing

Technology Interest
Clinical Computers	Yes	No	When:
Digital Radiography	Yes	No	When:
Intraoral Cameras	Yes	No	When:
Inventory Tracking	Yes	No	When:
Patient Education	Yes	No	When:
Office Messaging	Yes	No	When:
Image Software	Yes	No	When:
Patient Entertainment	Yes	No	When:
Lab Tracking	Yes	No	When:
Other

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