Send your testimonialPlease share with us your experience as a member of the National Dental Practice-Based Research Network (also known as the Nation’s Network)"*" indicates required fieldsEmail* Name First Last Degree(s):Primary practice name:Location of practice: City State / Province / Region Practice Website:Tell us about one activity you participated in the Network. What was it, and why did you enjoy it?Why being a member of the Network is important to you?Would you like to share any ideas or other thoughts with us?Please upload a picture of you or you and your practice team. Drop files here or Select filesAccepted file types: jpg, gif, png, pdf, Max. file size: 400 MB, Max. files: 3.You can also email them to nationaldpbrn@uab.edu, if you prefer.Please upload a video with your testimonial. Drop files here or Select filesAccepted file types: mp4, mov, avi, flv, mkv, mpeg, wmv, mp4v, mjpeg, Max. file size: 400 MB, Max. files: 5.You can also email them to nationaldpbrn@uab.edu, if you prefer.Consent for release of information: Do you authorize the National Dental PBRN to publish your responses with your name and picture to disseminate the Nation's Network? I agree.This form is to document that the National Dental Practice-Based Research Network has your authorization to record your participation, appearance, statements of support, photograph, or other image, for network professional and educational purposes. These purposes could include network presentations at professional and scientific meetings, network e-updates and news items, use of this information at the network web site (NationalDentalPBRN.org), social networking sites (Facebook, Instagram, LinkedIn, YouTube, and Twitter) and a list of practitioner-investigators who participated in specific network studies and are therefore part of the “National Dental PBRN Collaborative Group” for that study, as described on the Publications page at NationalDentalPBRN.org. This information will remain the property of The National Dental PBRN unless you request its return or change your mind about your permission for its release. Please contact Muna Anabtawi, National Program Manager at (205) 934-2578 to request that we no longer release that information. If you have any questions regarding this, you may contact the Office of the IRB (OIRB) at (205) 934-3789 or 1-800-822-8816. If calling the toll-free number press the option for “all other calls” or for an operator/attendant and ask for extension 4-3789. Regular hours for the OIRB are 8:00 a.m. to 5:00 p.m. Central time, Monday through Friday.If you are not the practitioner, by adding your name below, you confirm that you have submitted this form on behalf of the practitioner and have authorization from the practitioner to do so.The National Dental Practice-Based Research Network is supported by the National Institute of Dental and Craniofacial Research (NIDCR), part of the U.S. National Institutes of Health (NIH)(grants U19-DE-028717 and U01-DE-028727)Δ