Tell Us Your Story Fill out the form below for a chance to receive complimentary dental services from Dr. Cress at the Center for Craniofacial & Dental Sleep Medicine. Name* First Last Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Email* Your Story*What is your problem? Why should you be considered for complimentary services?Your Photo(s)*Upload a photo of your smile Drop files here or Accepted file types: jpg, gif, png. Release* I understand that any information submitted through this campaign becomes the exclusive ownership of Colony Dental and may be used by Colony Dental and/or Dr. Samuel Cress without further written consent by submitter. For valuable consideration received, I grant to Dr. Samuel Cress and Colony Dental "Content Owner" the absolute and irrevocable right and unrestricted permission concerning any photographs and textual content "Content" that I have submitted in this form or in which I may be included with others, to use, reuse, publish, and republish the content in whole or in part, individually or in connection with other material, in any and all media now or hereafter known, including the internet, and for any purpose whatsoever, specifically including illustration, promotion, art, editorial, advertising, and trade, without restriction as to alteration; and to use my name in connection with any use if Content Owner so chooses. I release and discharge Content Owner from any and all claims and demands that may arise out of or in connection with the use of the text and photograph submissions, including without limitation any and all claims for libel or violation of any right of publicity or privacy. This authorization and release shall also inure to the benefit of the heirs, legal representatives, licensees, and assigns of Content Owner, as well as the person(s) for whom he/she collected the Content. I am a legally competent adult and have the right to contract in my own name. I have read this document and fully understand its contents. This release shall be binding upon me and my heirs, legal representatives, and assigns. NameThis field is for validation purposes and should be left unchanged.