Whistelblower

Name Phone Title Practice Office Manager Regional Director Managing Dentist Date of Report Description of suspected Code of Conduct compliance violation (Be as specific and detailed as possible) Date of suspected violation Persons Involved Under what circumstances did you come to learn of the incident/suspected violation described above Do you have evidence to prove the allegation(s)? If so, please describe in detail Would you be willing to discuss the above allegation(s) with a PERFECT TEETH™ Compliance Officer, PERFECT TEETH™ Board of Directors, or a law enforcement official? Yes No If NO, under what circumstances would you consider discussing the allegation(s)? Have you discussed the allegation(s) with anyone else? Yes No If YES, with whom? Date(s) of discussion Do you have any further information to provide or any suggestions for verifying the allegation(s) described above? Are you aware of any other individuals who may be able to provide additional information regarding the above allegation(s) (Please indicate their names and any further details so that we are able to contact them directly)

Note: PERFECT TEETH™ will take every measure to ensure the confidentiality of the above information. However, there may be unforseen circumstances where disclosure of this information may become necessary.