Evanesce Experience

Information collected in this section will be used to issue and deliver the earn checks after evaluations are completed.

First Name*

Last Name*

Email*

Password*

Confirm Password*

Contains at least 10 characters
Contains both uppercase and lowercase letters
Includes at least one number
Contains at least one special character

Address One*

Address Two

City*

State*

Zip Code*

Phone Number*

Dental License Number*

License State*

NPI - National Provider Identification*

Invoice Number*

Invoice Date*

Sales Order Number*

Total Spend On Products*

Rounded to the nearest dollar

Please upload your invoice(s) as proof of purchase*

Maximum file size: 5MB.
Accepts PDF, JPG, JPEG and PNG files.

By checking this box, I consent to receive emails relating to this program.

By checking this box, I confirm that I have read, understood, and agree to the Terms and Conditions of the Evanesce Experience program. I acknowledge that eligibility and payment are subject to verification. I consent to the collection and use of my personal information by Axiom, and authorize Axiom to share my information with Den-Mat Holdings, LLC and its affiliates for the purposes of administering the promotion; collecting testimonials and market feedback for marketing purposes and future product development; and facilitating related follow-up communications, including Sunshine Act reporting.

Terms and Conditions Qualifying purchases must include any combination of eligible Evanesce product totaling $600 or more, after discounts, on a single invoice with promo code EVX applied. Eligible products include: Evanesce, Evanesce Silk, Evanesce Flow, Evanesce Bulk Cure, and Evanesce Injectable. Registration must be completed within 30 days of the qualifying invoice date. Evaluations must be completed within 30 days of registration. Payment of $200 per completed evaluation (maximum of 3 per customer, up to $600 total) will be issued via check to the address provided at registration. Each evaluation will be paid separately ($200 per completed evaluation) following verification of eligibility and successful evaluation submission. One offer per customer. Offer valid for U.S. customers only, excluding any states where gift bans apply: Minnesota & Vermont. Clinician's Choice reserves the right to modify or terminate this promotion at any time without prior notice. Purchases made prior to the termination date will remain eligible, provided registration is completed within 30 days of qualifying invoice and evaluations are completed within 30 days of registration. Clinician's Choice will report any payments made to you under this program to CMS as required by the Patient Protection and Affordable Care Act of 2010. By completing the Evanesce Experience, I understand, give and grant to Den-Mat Holdings, LLC dba Clinician's Choice ("Clinician's Choice"), its licensees, successors and assigns (collectively, the "licensed parties"), in perpetuity (the "Term"), all right, title and interest to use, publish, copyright, broadcast, reproduce, reuse, republish, edit, or "shorten for purposes of copy, my name, survey feedback and testimonial statement(s), as such shared in the survey, (in any medium), throughout the world, in any and all media and types of advertising and promotion now known, or hereafter developed, to the extent said matters relate to Clinician's Choice and its products and services. If you do not wish for your testimonial or survey responses to be used for marketing purposes, you may opt out by emailing support@theevanesceexperience.com prior to survey submission.