Please tell us how to contact you...

First Name *

Last Name *

Legal Business Name: *

Street Address *

Suite Number

State *

Other

Zip/Postal Code *

Email Address *

Phone Number *

How did you hear about us? *

A little bit about your business and your needs...

Type of business *

How many offices do you have? *

Do you own a scanner *

Types of procedures you offer (select all) *

Dentures

Overdentures

Fixed Dentures

Est. number of dentures, overdentures or hybrids you make each month? *

I'm a member of The Dental Cooperative? *

Yes

No

I'm interested in AvaDent's free patient education software? *

Yes

No

I'm interested in AvaDent's free patient referral program? *

Yes

No

When we ship, where do you want it to go?

Business Name: *

First Name *

Last Name *

Street Address *

Suite Number

City *

State *

Zip Code *

Not charging you yet, but we need this information too :)

I certify that I am the authorized holder and signer of the credit card referenced below. I certify that all information below is complete and accurate. I hereby authorize AvaDent to retain my credit card information set out above and to charge such card immediately for full payment for all charges invoiced to my (or my company’s) account at any time by AvaDent and agree that any later dispute with respect to any amount so charged will be handled by direct communication with AvaDent and will not invalidate my authorization for such charge to my card as herein described. *

I AGREE

Name on Card *

Credit Card Number *

Billing Address *

City *

State *

ZIp *

Credit Card Type *

Expiration Date (mm/yy) *

Verification *