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All information below must be for the Doctor requesting services. If you are an individual who is completing this form on behalf of a Doctor, please do not enter your own name or information


Name*
This is to identify your number if you call in later, we will not call unless requested
Practice Location*
Office Time Zone*
How many dentists are at your address/office in total (including associates and/or specialists even if part time)?*
Additional Doctor's Name:
Do you have ownership in more than one location?*
Is this a practice purchase or acquisition from another dentist in which you are taking over patient charts?*


All practice purchases are treated as Established Practices. Please visit the Established Practice Inquiry Form for our Established contact form

Will you be sharing office space with another doctor/practice that currently accepts PPOs?*
Will your startup be part of a DSO?*
Have you signed a lease for your space or closed on your property?*
Have you formed your corporation and confirmed your Tax ID/EIN for your startup practice with the IRS?*
Was a previous dental practice located in your startup space?*
If your address is new (new construction, new suite/unit number), have you checked with your local government and the US Postal Service that your address is confirmed and recognized?*


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Please give your best estimation based upon when you would like to see your first patients in your new office.
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How did you hear about us?*

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