Humanitarian Product Request Form

All humanitarian requests must be submitted using this form. We will review your submission and respond within the next two weeks.

Organization Details

Contact Name *
Organization *
Non-profit Tax ID#
Dentist / RDH *
The above dentist is attending this mission

Dental Office Details

Address Line 1 *
Address Line 2
Suite #
City *
State *
ZIP Code *
County *
Phone Number *
Email Address *

You will be contacted via (email, telephone, etc.) once the request has shipped.

Brief Summary of Organization/Mission:

Brief Summary of Organization/Mission *

Humanitarian Mission Details

Target Population
Location of Mission *
Trip Start Date *
Trip End Date *
Date Product is Needed *
Number of Volunteers *
1. Dentists
2. Hygienists
3. Dental Assts
4. Other
5. Total *

Estimated number of patients served weekly OR during humanitarian trip *
Treatment Procedure Performed *

Products Needed
(Please note that the requested products are NOT a guarantee on what will be sent.) *

Terms and Conditions

I consent to allow Ultradent to use the provided information to contact me regarding and to evaluate my request. If this request is approved, as consideration for receipt of Ultradent product(s) donated for humanitarian purposes I certify that:(i) donated products will not be sold or transferred to anyone for any purpose not consistent with the statements made in this request form: (ii) all dental services required in connection with use of donated products shall be provided to the patient(s) free of charge: (iii) donated products will be used in accordance with their labeled instructions and (iv) I agree to hold harmless Ultradent, The Diversity Foundation and affiliates from any and all liability for use of the donated product(s).

By checking the box you agree to the terms and conditions above *

Number of Volunteers *

Terms and Conditions