Healthy Behaviors Incentive Form

To get your gift card you must:

Receive the qualifying service below within 90 days of enrollment 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*

Email*

Mailing address*

City*

Zip code*

Gift cards will be delivered within 12-16 weeks from submission date.

Last modified on March 7, 2025

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