Step 1 of 8 12% What type of practice/organization are you a part of?(Required) Single Location Practice Multi-Location Practice Lab, University, or Other To assist you better, please call 1-800-522-4636 or email [email protected] for more information. Thank you! If a single location practice, are you a member of a DSO?(Required) Yes No A DSO (Dental Support Organization) contracts with dental and orthodontic practices to provide critical business management and support including non-clinical operations. (Example: Smile Doctors, MB2 Dental, Tots to Teens) If you are unsure, please check with the doctor at your practice.Name of DSO(Required) DSO-Unique ID If a DSO, are you centrally billed?(Required) Yes No Are you a member of a purchasing group?(Required) Yes No Purchasing groups are member-based organizations that leverage purchasing power without having to meet predetermined volume requirements. (Example: Elite Dental Alliance, Schulman Group, Galler Group) If you are unsure, please check with the doctor at your practice.Purchasing Group Name(Required) Purchasing Group Unique ID If a multi-location practice, are you a member of a DSO?(Required) Yes No Name of DSO(Required) DSO-Unique ID If a DSO, are you centrally billed?(Required) Yes No Are you a member of a purchasing group?(Required) Yes No Purchasing Group Name(Required) Purchasing Group Unique ID(Required) Within your group, are you centrally billed?(Required) Yes No Central Billing Contact Name(Required) First Last Central Billing Contact Phone Number(Required)Central Billing Statement Email Address(Required) Central Invoice/Statement email box (if any) Number of Locations(Required) Practice Information Practice Name Practice Address Actions Edit Delete There are no Practices. Add Practice Maximum number of practices reached. Practice Name(Required) Practice Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Practice Primary Contact Name(Required) First Last Practice Primary Contact Role/Title: e.g. Office Manager(Required) Practice Primary Contact Email Address(Required) Practice Primary Contact Phone Number(Required)Billing Contact Name (if different from above) First Last Billing Address (if different than above) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Billing Phone Number (if different than above)Billing Email (if different than above) Doctor Information Name Area of Specialty Actions Edit Delete There are no Doctors. Add Doctor Maximum number of doctors reached. Shipping Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code How will you submit a case?(Required) Digital Impression Stone Impression If digital, what scanner does your practice use? iTero Trios Carestream CEREC Omnicam Medit Other Days you cannot receive deliveries (select all that apply)(Required) Monday Tuesday Wednesday Thursday Friday Saturday Sunday None of the Above Receive Mailed Statements(Required) Yes ($10 monthly service fee) No What email address would you like to receive your digital statement at?(Required) Enroll in Autopay by credit card?(Required) Yes No If yes, please contact customer service at 1-800-522-4636Where did you hear about us? (select all that apply) Tradeshow DSO/Purchasing Group Website/Google Word of Mouth Social Media Which appliances do you most typically use at your practice? (Select all that apply) Class II (Herbst and MARA) Aligners Expansion/Distalization Appliances 3D Indirect Bonding Habit Appliances Fixed Lingual Retainers Invisible Retainers Splints TADs Hawley Retainers How many new patient starts does your practice typically do per month? 0-15 16-30 31-45 46-60 60+ CAPTCHACommentsThis field is for validation purposes and should be left unchanged.
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