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    Add'l Drs. can be added later.
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    This is the address we'll use to ship your cases, so please enter it exactly how it should appear on shipping labels.
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    This is based on the building type. Offices located in houses are considered residential for shipping.
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    • Please Select
    • Alabama
    • Alaska
    • Arizona
    • Arkansas
    • California
    • Colorado
    • Connecticut
    • Delaware
    • District of Columbia
    • Florida
    • Georgia
    • Hawaii
    • Idaho
    • Illinois
    • Indiana
    • Iowa
    • Kansas
    • Kentucky
    • Louisiana
    • Maine
    • Maryland
    • Massachusetts
    • Michigan
    • Minnesota
    • Mississippi
    • Missouri
    • Montana
    • Nebraska
    • Nevada
    • New Hampshire
    • New Jersey
    • New Mexico
    • New York
    • North Carolina
    • North Dakota
    • Ohio
    • Oklahoma
    • Oregon
    • Pennsylvania
    • Rhode Island
    • South Carolina
    • South Dakota
    • Tennessee
    • Texas
    • Utah
    • Vermont
    • Virginia
    • Washington
    • West Virginia
    • Wisconsin
    • Wyoming
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    • Please Select
    • Afghanistan
    • Albania
    • Algeria
    • American Samoa
    • Andorra
    • Angola
    • Anguilla
    • Antigua and Barbuda
    • Argentina
    • Armenia
    • Aruba
    • Australia
    • Austria
    • Azerbaijan
    • The Bahamas
    • Bahrain
    • Bangladesh
    • Barbados
    • Belarus
    • Belgium
    • Belize
    • Benin
    • Bermuda
    • Bhutan
    • Bolivia
    • Bosnia and Herzegovina
    • Botswana
    • Brazil
    • Brunei
    • Bulgaria
    • Burkina Faso
    • Burundi
    • Cambodia
    • Cameroon
    • Canada
    • Cape Verde
    • Cayman Islands
    • Central African Republic
    • Chad
    • Chile
    • China
    • Christmas Island
    • Cocos (Keeling) Islands
    • Colombia
    • Comoros
    • Congo
    • Cook Islands
    • Costa Rica
    • Cote d'Ivoire
    • Croatia
    • Cuba
    • Curaçao
    • Cyprus
    • Czech Republic
    • Democratic Republic of the Congo
    • Denmark
    • Djibouti
    • Dominica
    • Dominican Republic
    • Ecuador
    • Egypt
    • El Salvador
    • Equatorial Guinea
    • Eritrea
    • Estonia
    • Ethiopia
    • Falkland Islands
    • Faroe Islands
    • Fiji
    • Finland
    • France
    • French Polynesia
    • Gabon
    • The Gambia
    • Georgia
    • Germany
    • Ghana
    • Gibraltar
    • Greece
    • Greenland
    • Grenada
    • Guadeloupe
    • Guam
    • Guatemala
    • Guernsey
    • Guinea
    • Guinea-Bissau
    • Guyana
    • Haiti
    • Honduras
    • Hong Kong
    • Hungary
    • Iceland
    • India
    • Indonesia
    • Iran
    • Iraq
    • Ireland
    • Israel
    • Italy
    • Jamaica
    • Japan
    • Jersey
    • Jordan
    • Kazakhstan
    • Kenya
    • Kiribati
    • North Korea
    • South Korea
    • Kosovo
    • Kuwait
    • Kyrgyzstan
    • Laos
    • Latvia
    • Lebanon
    • Lesotho
    • Liberia
    • Libya
    • Liechtenstein
    • Lithuania
    • Luxembourg
    • Macau
    • Macedonia
    • Madagascar
    • Malawi
    • Malaysia
    • Maldives
    • Mali
    • Malta
    • Marshall Islands
    • Martinique
    • Mauritania
    • Mauritius
    • Mayotte
    • Mexico
    • Micronesia
    • Moldova
    • Monaco
    • Mongolia
    • Montenegro
    • Montserrat
    • Morocco
    • Mozambique
    • Myanmar
    • Nagorno-Karabakh
    • Namibia
    • Nauru
    • Nepal
    • Netherlands
    • Netherlands Antilles
    • New Caledonia
    • New Zealand
    • Nicaragua
    • Niger
    • Nigeria
    • Niue
    • Norfolk Island
    • Turkish Republic of Northern Cyprus
    • Northern Mariana
    • Norway
    • Oman
    • Pakistan
    • Palau
    • Palestine
    • Panama
    • Papua New Guinea
    • Paraguay
    • Peru
    • Philippines
    • Pitcairn Islands
    • Poland
    • Portugal
    • Puerto Rico
    • Qatar
    • Republic of the Congo
    • Romania
    • Russia
    • Rwanda
    • Saint Barthelemy
    • Saint Helena
    • Saint Kitts and Nevis
    • Saint Lucia
    • Saint Martin
    • Saint Pierre and Miquelon
    • Saint Vincent and the Grenadines
    • Samoa
    • San Marino
    • Sao Tome and Principe
    • Saudi Arabia
    • Senegal
    • Serbia
    • Seychelles
    • Sierra Leone
    • Singapore
    • Slovakia
    • Slovenia
    • Solomon Islands
    • Somalia
    • Somaliland
    • South Africa
    • South Ossetia
    • South Sudan
    • Spain
    • Sri Lanka
    • Sudan
    • Suriname
    • Svalbard
    • eSwatini
    • Sweden
    • Switzerland
    • Syria
    • Taiwan
    • Tajikistan
    • Tanzania
    • Thailand
    • Timor-Leste
    • Togo
    • Tokelau
    • Tonga
    • Transnistria Pridnestrovie
    • Trinidad and Tobago
    • Tristan da Cunha
    • Tunisia
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    Please Select
    • Please Select
    • Multi-Specialty
    • Orthodontic
    • Pediatric
    • General
    • Oral Surgery
    • Periodontic
    • Endodontic
    • Orofacial Pain
    • Prosthodontic
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  • 24

    🔒 Credit Card is Required to Activate Your Account.

    Perfect Finish Ortho Lab requires a credit card on file to activate and maintain an active account.

    After you submit your first case and your lab account is created, you will receive your Customer Portal login information. You will then be asked to securely enter your credit card information through the Customer Portal or through a secure payment link provided by our office.

    Please note:

    • Adding a card on file does not automatically charge your card.
    • A valid credit card will be required before the start of fabrication.
    • Payments can be made at any time through the Customer Portal
    • For automatic payments, AutoPay is available.
    • Autopay is processed on the 6th of each month for any outstanding balance.
    • If an account balance becomes 90 days past due, Perfect Finish Ortho Lab reserves the right to charge the card on file for the outstanding balance.  You will be notified prior to any past-due charge being processed.

     

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    Applies to Credit Card Payments Only. We will automatically process your card on the 6th of the month.
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    Please select all that apply.
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  • 29

    Please Note:

    We accept digital scans through EasyRx prescription software.  This is a cloud-based software that is HIPAA compliant and integrates with many IOS Systems (iTero, 3Shape TRIOS, Medit, Dexis, Allied Star, etc).  

    You can also upload .stl files, patient photos, case designs, etc.

    We cover the cost to submit for all new EasyRx customers.

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    Please Select
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    • YES - I will connect to your lab on EasyRx
    • NO - Please send me an EasyRx invitation
    • I don't know
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    This email will be used as the EasyRx Login ID and will receive case notifications and clinical communication. Leave blank if same as main office email.
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  • 32

    🎉Almost Finished!😄 

    Just a few more questions—we promise!

    Our marketing team is a little nosey (they prefer the term “enthusiastically curious”) and would love to know a few fun things to help us support your practice even better.

    Hang in there—you're in the home stretch! 🏁

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    Check all that apply
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    Please select all that apply.
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    Multiple Locations

    Please complete a separate form for each location. Each location is set up as an individual account to ensure accurate account setup, shipping, billing, and case management.

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  • 38
    Please Select
    • Please Select
    • Referral/Word of Mouth
    • Social Media (Facebook, Instagram, LinkedIn, etc)
    • Print Promo/Mailer
    • Convention/Conference/Meeting
    • Internet Search (Google, Bing, etc)
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    Select all that apply
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  • 42

    WHAT TO EXPECT AFTER YOU SUBMIT THIS FORM?

    For New Customers: one of our representatives will be in touch with you within 24 business hours.  For immediate assistance, please call our office at 973-527-7844.

    For Clients submitting Digital Cases- you will receive an email to the one you provided for clinical notifications.

    This email will come from "info@easyrxcloud.com" with the subject line: "Perfect Finish Ortho Lab (NJ) invites you.

    This email will include your EasyRx login information, a link to login to EasyRx, and a link to set up training with EasyRx at your convenience.

    *Please Note* this will not be automatic and may take up to 24 hour business hours (not including weekends) to receive this email.

    For Clients submitting Physical Cases or Items (Bands, Parts, etc): you can access our mailing labels from our website: www.perfectfinishortho.com and go to Resources.

     

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  • 43

    Terms & Conditions

     

    Please review the complete Terms and Conditions here.
    (Clicking the link will open the document in a new page.)

    On the next page, you will be asked to acknowledge that you have accessed and read the Terms and Conditions and that, by continuing with this form and by submitting cases to our lab (digital or physical), you agree to these Terms and Conditions and agree to abide by them.

    A copy of our Terms and Conditions will also be included in your Welcome Folder for your records.

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