Rapid Assessment of Evidence: Research Request Form

* What is your concern about the orthodontic product/appliance/technique of interest to you?

* Name of manufacturer:

* Name of product/appliance/technique:

Product website:

* How often do you use this product/appliance/technique in your office?

* What sources have you consulted already? (please list all sources)

If Yes, what was the response?

* Name:

* Office Address:

* City:

* State:

* Zip code:

* Daytime Telephone number:

* Email: