Clone of C3 Dental Marketing State Network

1
Which listing package works best for you?* This field is required.Choose your desired Listing package
Essential Listing Package
Pro Listing Package
2
Name of Dental Practice/Office* This field is required.Please provide the name of the dental office the listing is being created for.
3
Primary Contact:* This field is required.Please provide the name of the person of contact managing the account. Ex. Office Manager or Dentist.
First Name
Last Name
4
Primary Phone Number* This field is required.Please provide a reliable number that you may be contacted if needed. Your phone number will not sold, rented, shared or distributed.
Area Code
Phone Number
5
Primary Email* This field is required.Emails are verified to maintain email accuracy account communications made via email. Your emails will not sold, rented, shared, or distributed and only used for business communication.
example@example.com - Verification helps to minimize false email accounts.
Email Verified
The verification code has been sent to some@email.com
Please check your mailbox and paste the code below to complete verification
••••
Didn't receive verification code?or
Receiving the email may take a few minutes, thank you for your patience!
6
What URL would you storefront directed to?* This field is required.This can be a social media link, homepage to the practice and allows access to assets or needed information.
Ex. Copy and paste the URL of your dental practice.
7
What is the primary and secondary dental service provided?* This field is required.Please provide what area of dentistry your practice fits under.
General Dentistry
Cosmetic Dentistry
Oral and Maxillofacial Surgeon
Pediatric Dentistry
Orthdontist
Periodontist
Endodontist
Prosthodontist
Oral Pathologist
8
Do you accept most insurances?
YESNO
9
Upload Your Practice LogoIf you have a website we will try to get it from your website or social channel. We will place a generic dental logo if you do not have one.
10
Choose the State Listing Network * This field is required.Please select the primary State your Practice resides.
11
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Great Product Name
$20
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Size:Small
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Great Product Name
$20
Quantity:1
Size:Small
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Great Product Name
$20
Quantity:1
Size:Small
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ORDER SUMMARY
Total costUSD
State Network ListingEssential Setup (one-time): $399.99Monthly Hosting: $50.00/month - SKU#C3DM-ES | Pro Setup (one-time): $599.99 Monthly Hosting: $50.00/month- SKU#C3DM-PRO.
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Pro Setup
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State Listing
Premium Listing -Page 1 (Limited Spots)Premium Page 1 Featured Add-On+$50/mo. add-on (Page 1 only). No additional setup fee. Your monthly becomes $100/mo. total while Featured is active.
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Alabama
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
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
States
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12
Terms and Conditions* This field is required.
Should be Empty: