Hyg Course SimplyPerio Req Form

Kois Center | Hygiene Course
SimplyPerio Requisition Form

Please fill out the form below with the requested information. We request that you double-check your submitted barcode number, as this number is what connects you to your sample. If you have any questions, comments, or concerns, please see one of Dr. Thompson’s Hygiene Course Support Staff.

Kois Seat Number

Please place your seat number into this field, it will assist us in matching your sample to your data

Please enter a number from 1 to 40.

Barcode #(Required)

Please type your SimplyPerio barcode number into this field. Please double check for accuracy

Name(Required)

Please enter your name as it appears on your Kois Center name card

First Last

Date of Birth(Required)

Email(Required)

Enter Email Confirm Email

Office Name(Required)

Office Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone(Required)

Necessary

Always Active

Necessary cookies help make a website usable by enabling basic functions like page navigation and access to secure areas of the website. The website cannot function properly without these cookies.

Marketing cookies are used to track visitors across websites. The intention is to display ads that are relevant and engaging for the individual user and thereby more valuable for publishers and third party advertisers.

Name	Domain	Purpose	Expiry	Type
Google Analytics	wellnessdentistrynetwork.com	This is a web analytics service. With this, the user can measure the advertising return on investment "ROI" as well as track user behavior with flash, video, websites and applications.	1 day	HTTP

Analytics cookies help website owners to understand how visitors interact with websites by collecting and reporting information anonymously.

Name	Domain	Purpose	Expiry	Type
Google Maps	wellnessdentistrynetwork.com	This is an integrated map service.	1 day	HTTP
reCaptcha	wellnessdentistrynetwork.com	This is a service that checks whether data is entered by a human or by an automated program.	1 day	HTTP
YouTube Video	wellnessdentistrynetwork.com	This is a video player service. It can be used by user to watch, like, share, comment and upload videos.	1 day	HTTP
Google Tag Manager	wellnessdentistrynetwork.com	This is a tag management system. Via Google Tag Manager, tags can be integrated centrally via a user interface. Tags are small sections of code that can track activities. Script codes of other tools are integrated via the Google Tag Manager. The Tag Manager allows to control when a particular tag is triggered.	1 day	HTTP

Preferences

Preferences

Preference cookies enable a website to remember information that changes the way the website behaves or looks, like your preferred language or the region that you are in.
Unclassified

Unclassified

Unclassified cookies are cookies that we are in the process of classifying, together with the providers of individual cookies.

Kois Center | Hygiene CourseSimplyPerio Requisition Form

Kois Center | Hygiene Course
SimplyPerio Requisition Form