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
Firs Name
Last Name
Choose Speciality
Please Select
General Practitioner
Endodontist
Oral Surgeon
Orthodontist
Pediatric Dentist
Periodontist
Prosthodontist
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Practice Location
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Office Time Zone
*
Eastern
Central
Mountain
Pacific
How many dentists will be at your new startup address/office in total (including associates and/or specialists even if part time)?
*
1
2
3 or more
Do you have ownership in more than one location?
*
Yes
No
Is this a practice purchase or acquisition from another dentist in which you are taking over patient charts?
*
Yes
No
Will you be sharing office space with another doctor/practice that currently accepts PPOs?
*
Yes
No
Will your startup be part of a DSO?
*
Yes
No
Have you signed a lease for your space or closed on your property?
*
Yes
No
Have you formed your corporation and confirmed your Tax ID/EIN for your startup practice with the IRS?
*
Yes
No
Was a previous dental practice located in your startup space?
*
Yes
No
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?
*
Yes
No
When do you plan to open your new office?
*
Yes
No
When do you plan to open your new office?
*
-
Month
-
Day
Year
Date
How did you hear about us?
*
DentalTown
Social Media
Consultant Referral
A Previous Unlock the PPO Client
Submit
Should be Empty: