Account Set Up Form

Doctor's First Name*

Doctor's Last Name*

Practice Name*

Website URL

Phone Number*

Best number to call for case correspondence

Email*

Best email for case correspondence

Shipping Address, City, State, Zipcode*

Billing address is the same as shipping

Billing Address, City, State, Zipcode

Billing Email

How did you hear about us?*

If you belong to a buying club or DSO, please list the name:

What brand of intra oral scanner do you use?*

On average, what is your volume of crown/bridge cases per month?*

On average, what is your volume of denture/partial cases per month?*

Do you have a need for abutments, occlusal guards, or retainers?*

Yes

Do you need shipping supplies?*

Yes