Healthy Behaviors Incentive Form

To get your gift card you must:

Receive the qualifying service below within the first 90 days of signing up with DentaQuest.
Complete and submit this form.

Please briefly explain your license request below

Check the qualifying service(s) you received:

Molar(s) sealed

Date of service

Member Information

First Name

Last Name

Date of Birth

Phone

Mailing address

City

Zip code

SoonerSelect Member ID

Your SoonerSelect Member ID number is the 9- or 10-digit number on the front of your card

Last modified on October 8, 2024

A newsletter with tips and information to improve your oral health.