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:

Members ages 6-14 years Molar(s) sealed

Date of service

Member Information

First Name

Last Name

Date of Birth

Phone

Mailing address

City

Zip code

SoonerSelect Member ID

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

Last modified on March 7, 2025

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