GPSFORDENTAL67921 Email Marketing -

Office Lab Account Creation Form

This form provides us with all of the necessary information to set up all of your accounts for you and your team members! Please ensure you have your team member names and logins for us to complete your set up.

All fields are required.

Practice Name *

Practice Phone *

Dentist Provider First Name *

Dentist Provider Last Name *

Cell Phone *

What is the Practice Address - where cases are shipped to *

Provider NPI # *

Email for accounting management *

Click below to activate account communications

Active Clients

Point of Contact Full Name *

Point of Contact Email *

Lab Credit Card # (Card on file required for account) *

Credit Card Expiration and CV *

You must choose subscribe *

Subscribe

Unsubscribe

Lead RDH Full Name

RDH Email

Treatment Coordinator Full Name

Treatment Coordinator Email

Do you have a CBCT for this location?

Do you have a digital impression scanner for this location (If yes, which one)? *

WHO REFERRED YOU? *