Remi Dental Care Center Form

Welcome to REMI Partner Information Form

We’re excited to partner with your dental practice to deliver personalized care for your patients. Please fill out this form to get started
Dental Practice Information
Dental Practice Name
Address

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number
Please enter a valid phone number.

Point of Contact Information
Full Name

First NameLast Name
Position
Email
example@example.com
Phone Number
Please enter a valid phone number.

How many patients require mouth guards or retainers every month on average?
When would you like to receive the impression kit
Should be Empty: