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John Delplanche, DMD, MS
Healthy Grins Always Win!
It’s simple - at your next dental exam, just have your dentist or hygienist sign this
form and then return it to our office. You will receive 10 Reward Tokens and we
will enter your dentist or hygenist into a drawing to win a fun prize too!!
Healthy Grins Always Win Entry Form:
The health of your smile is very important to us. Make sure you see your dentist every 3-6
months for an examination and cleaning while undergoing orthodontic treatment.
Patients Name: Dentists Name: Print Hygienist Name & Signature: Date of Recent Dental Visit: Next Appointment: Comments: This form is available on our website at