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New Account Form
Office Information (shipping address)
Doctor Name
*
Practice Name
*
Doctor Email
*
Main Phone #
*
Fax #
Billing Phone #
Doctor Cell #
Other Number
Street Address
*
Apartment, suite, etc
City
*
State/Province
*
ZIP / Postal Code
*
Which days is the practice open?
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
How did you hear about us?
*
Incisive
CSDA
Which Dental School did the doctor attend
Office Contacts
Billing Questions
Scheduling Questions
Office Manager
Doctors Assistant
Billing
I would like my statements emailed to me
Yes
No
Statement Email Address
Method of Payment
*
COD
End of Month
Credit Card
Last 4 of Credit Card
0 / 4
Name
Practice
Billing Address
Are shipping and billing address the same?
*
Yes
No
Street Address
*
Apartment, suite, etc
City
*
State/Province
*
ZIP / Postal Code
*
Preferences
Which product line do you prefer?
Signature
DaVinci
Essentials
Unsure
Impression Type
*
Digital
Analog
Both
Crown and Bridge
Occlusal Staining
None
Light
Medium
Heavy
Proximal contacts
Light
Medium (Default)
Heavy - scrape cast
Occlusal contacts
Light (0.3mm sub)
Medium (0.1mm sub)(Default)
Heavy - thin myler pulls through
Extra Heavy - touching opposing model
If no occlusal room
Call Doctor
Reduce Prep
Send Reduction Coping
Adjust Opposing
Metal Occlusal
Margin Design
Porcelain Shoulder
Metal- Porc Junction (default)
360- degree Porcelain Shoulder
Gingival Embrasures
Closed
Open
Pontics
Sanitary / Hygienic
Conical / Bellet
Modified Ridge Lap (default)
Full Ridge Lap
Ovate
Implant
Manufacturer Preference
OEM
Generic
Specific Brand (if any)
Abutment Type
Stock Ti-Base
Stock Titanium
Custom Titanium
Custom Zirconia
Occlusal Table
Normal Width
Narrow (3/4 width)
Retention Method
Cement
Screw
Abutment Emergence
Hygienic with cylindrical emergence
Natural anatomical emergence (default)
1/2 pontic ridge lap (implant at tissue level) design simulates natural emergence
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