Oral Health Kit Request Form

I would like to order the following for my agency / organization:

Please note: Subject to Availability. Offices must be billing for ABC services to order dental kit boxes. 1 Box has 50 kits.

Kit Selection

Child Kit Box Infant Kit Box

Your Organization’s Name

Your Name

Your Email

CT Mailing Address (Street)

CT Mailing Address (City)

CT Mailing Address (Zip Code)

Your Phone

Do you need these for a specific event / date?

If Yes, date needed by

Thank you for helping your clients maintain good oral health.
Your Community Engagement Specialist will contact you regarding your order.