New Client Information Form

New Client Information Form

Please provide your practice and design preferences to help us serve you best.
Practice Information

Please provide your practice's key contact details.
Practice/Clinic Name*
Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Contact Person*

First NameLast Name
Email*
example@example.com
PhoneEmailText
Design Preferences

To save time on future prescriptions, please indicate your preferences. If not specified, standard protocols will be followed. We will always reach out if clarification is needed.
LightNormalHeavyWill specify each timeN/AOther
ShallowMediumDeepWill specify each timeN/AOther
LightMediumHeavyWill specify each timeN/AOther
Ridge LapModified Ridge LapOvateConicalWill specify each timeN/AOther
NormalHeavy & BroadNoneWill specify each timeN/AOther
NormalWide OpeningClosedWill specify each timeOther
YesNeverWill specify each timeN/AOther
Light (one coat)Medium (two coats)HeavyWill specify each timeN/AOther
Lingualized occlusionMonoplane occlusionBalanced occlusionWill specify each timeN/AOther
NoneLightHeavyWill specify each timeN/AOther
NeverOnly when scans are based off physical impressionAlwaysWill specify each timeN/AOther
NeverAlwaysWill specify each timeN/AOther
Flat planeMichiganAnterior biteWill specify each timeN/AOther
Scanner PortalDropboxWeTransferOther
3ShapeMeditiTeroStraumannShining3DOther (please specify below)
What milling/printing unit will you be using?
This helps us customize your design parameters.
Would you like us to communicate with your preferred outsource lab for printing/milling? If so, who?
We can collaborate directly with them and ensure our file types are compatible for easy production.
Invoice Options
Automatically charge a card on fileMail me an invoiceEmail me a payment linkCall me each billing cycle
Recurring payments information
WeekMonthQuarterOther
Charge on this date
(For example, the 1st of every month)
YesNo
Mail receipts to:

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
To cancel, contact: Name and email
Anything else you want us to know?
We're all ears!
Signature*
Date*

MonthDayYear
Date
Should be Empty:

New Client Information Form

Practice Information

Design Preferences

Invoice Options

Recurring payments information