Doctor Enrollment Form Doctor Enrollment Form How did you hear about us?*Qualident RepresentativeVendorFriend or ColleagueSeminarOtherWhich Company or Vendor? Name of Friend or Colleague: When and Where was the Seminar? Please specify where you heard about us: Doctor InformationDoctor Name* First Last License #* Cell PhoneEmail* Are You The Financially Responsible Party?* Yes No Financially Responsible Party Name* First Last Financially Responsible Party Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Financially Responsible Phone*Financially Responsible Party Email* Practice InfoClinic Name* Clinic Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Hours* Office StaffOffice Manager Front Office Assistants Hygienists Is your practice part of a group?* No Yes Name of group What type of impression are you using? Traditional Digital Please Choose A Digital impression TypeiTero3Shape TriosCerec3M True DefinitionCarestreamMedit i500OtherPlease keep me updated on the latest lab news including upcoming CE opportunities. Yes PhoneThis field is for validation purposes and should be left unchanged.
