Doctor Enrollment | Qualident Dental Lab

Doctor Enrollment Form

Doctor Enrollment Form

Would you like a starter kit?*
- Yes
- No
How did you hear about us?*
Which Company or Vendor?
Name of Friend or Colleague:
When and Where was the Seminar?
Please specify where you heard about us:
Doctor Information
Doctor Name*
First Last
License #*
Cell Phone
Email*
Are You The Financially Responsible Party?*
- Yes
- No
Financially Responsible Party Name*
First Last
Financially Responsible Party Address*
Street Address City State ZIP Code
Financially Responsible Phone*
Financially Responsible Party Email*
Practice Info
Clinic Name*
Clinic Address*
Street Address City State ZIP Code
Phone*
Hours*
Office Staff
Office Manager
Front Office
Assistants
Hygienists
Is your practice part of a group?*
- No
- Yes
Name of group
Name
This field is for validation purposes and should be left unchanged.

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Our Location

Qualident Dental Lab
5305 E 18th Street, Suite #100
Vancouver, WA 98661

(o) 1-360-695-7411
(t) 1-800-255-6427
(f) 1-360-695-6547

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A full service dental laboratory specializing in high end dental appliances.