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Is your spouse a dentist or in the dental industry?
Yes
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Do they own a practice or work as an associate?
Own a Practice
Work as an Associate
No Longer Practice
Work in the Industry
Where do they practice?
Who can we thank for referring you to IPS?
Dental School:
Year Graduated:
Post Graduate Education:
Residencies or Other Training:
State Licenses and #'s:
Professional Memberships (ADA/CDA/local dental society, etc.)
Study Club Membership:
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General
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Ortho
Oral Surgery
Pediatric
Endo
Perio
Prosthodontics
Do you have any associates or outside specialists?
Yes
No
Do you own or lease your space?
Own
Lease
Are you in-network or contracted with any insurance?
Yes
No
Are you contracted with Delta Premier?
Yes
No
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Month
-
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Spouse's Name
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Last Name
Is your spouse a dentist or in the dental industry?
Yes
No
Do they own a practice or work as an associate?
Own a Practice
Work as an Associate
No Longer Practice
Work in the Industry
Where do they practice?
Who can we thank for referring you to IPS?
Dental School:
Year Graduated:
Post Graduate Education:
Residencies or Other Training:
State Licenses and #'s:
Professional Memberships (ADA/CDA/local dental society, etc.)
Study Club Membership:
Specialty
General
Cosmetic
Ortho
Oral Surgery
Pediatric
Endo
Perio
Prosthodontics
Do you have any associates or outside specialists?
Yes
No
Do you own or lease your space?
Own
Lease
Are you in-network or contracted with any insurance?
Yes
No
Are you contracted with Delta Premier?
Yes
No
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