NAME*

Email*

OFFICE CONTACT PERSON* OFFICE CONTACT PERSON*SAME AS PERSON COMPLETINGOTHER

YOUR ROLE AT PRACTICE* YOUR ROLE AT PRACTICE*Owner/DoctorDoctorOwnerOffice ManagerInsurance CoordinatorCPA/CFPOther

PHONE*

Practice/Office Name*

YEARS IN BUSINESS* YEARS IN BUSINESS*JUST PURCHASED/PURCHASING1-56-1011-2021+I WANT TO SELL MY PRACTICE

PRACTICE ADDRESS*

CITY*

State* State*ALAKARAZCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNCNDNENVNHNJNMNYOHOKORPARISCSDTNTXUTVTVAWAWVWIWY

ZIP CODE*

DOCTORS NAME*

Practice Management Software Used* Practice Management Software Used*CurveDenticon/Planet DDSDentrixDentrix AscendEaglesoftEasy DentalOpen DentalSoftDentOther

Name Of Practice Management Software*

I Have Used Another PPO Company* I Have Used Another PPO Company*YESNO

Name of Other PPO Company Used

How Did You Hear About Us?* How Did You Hear About Us?*FaceBookInstagramAADOMMy State Dental AssociationMy CPA/CFPMy Supply RepA ColleagueOther

Which FB Group?

Which AADOM Tribe/Group?

Which State?

Which Supply Company?

I Heard From:

Carriers You Need Help With Carriers You Need Help With ALL Aetna BlueCross/BlueShield Careington Cigna Delta Dental DenteMax DHA/SunLife Ameritas GEHA/Connection Dental Guardian Humana Medicare/Medicaid MetLife Principal United Concordia United Healthcare Other

I HAVE READILY AND EASY ACCESS TO COPIES OF MY EOBS* I HAVE READILY AND EASY ACCESS TO COPIES OF MY EOBS* ELECTRONICALLY PAPER COPIES ONLY BOTH ELECTRONIC AND PAPER I CANT ACCESS THEM

Tell us what you are wanting/needing to accomplish*

I AM A RETURNING CLIENT I AM A RETURNING CLIENT YES NO

I HAVE MULTIPLE LOCATIONS I HAVE MULTIPLE LOCATIONS YES NO