New Customers Account Information Setup Auto Pay Account InformationWho opened account(Required)Title(Required)Referred By(Required)Doctor (Last, First)(Required)Dr. Birthday(Required)Practice Name(Required)License #(Required)Practice Type(Required) Restorative Prosthodontist Periodontist Oral Surgeon Laboratory Intraoral Scanner (Check all that apply)(Required) TRIOS Carestream iTero Sirona Other N/A Other Intraoral ScannerIs this a privately owned practice?(Required) Yes - Private Practice Principal Account Yes - Private Practice but Group Account No - DSO select Group Account Name of Dental Service Organization:Practice Manager NamePractice Manager Direct LinePractice Manager EmailContact InformationPractice Phone(Required)Practice Email(Required) Address(Required)Street AddressCity(Required)CityState(Required)AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificStateZIP Code(Required)ZIPDoctor Cell(Required)Doctor Email Case Coordinator NameCase Coordinator Direct LineCase Coordinator EmailAccounts Payable NameAccounts Payable Direct LineAccounts Payable EmailHours of Operation (Required)Hours of Operation(Required) MonTueWedThuFriSatSun12:00 am12:30 am1:00 am1:30 am2:00 am2:30 am3:00 am3:30 am4:00 am4:30 am5:00 am5:30 am6:00 am6:30 am7:00 am7:30 am8:00 am8:30 am9:00 am9:30 am10:00 am10:30 am11:00 am11:30 am12:00 pm12:30 pm1:00 pm1:30 pm2:00 pm2:30 pm3:00 pm3:30 pm4:00 pm4:30 pm5:00 pm5:30 pm6:00 pm6:30 pm7:00 pm7:30 pm8:00 pm8:30 pm9:00 pm9:30 pm10:00 pm10:30 pm11:00 pm11:30 pm12:00 am12:30 am1:00 am1:30 am2:00 am2:30 am3:00 am3:30 am4:00 am4:30 am5:00 am5:30 am6:00 am6:30 am7:00 am7:30 am8:00 am8:30 am9:00 am9:30 am10:00 am10:30 am11:00 am11:30 am12:00 pm12:30 pm1:00 pm1:30 pm2:00 pm2:30 pm3:00 pm3:30 pm4:00 pm4:30 pm5:00 pm5:30 pm6:00 pm6:30 pm7:00 pm7:30 pm8:00 pm8:30 pm9:00 pm9:30 pm10:00 pm10:30 pm11:00 pm11:30 pm12:00 am (next day)12:30 am (next day)1:00 am (next day)1:30 am (next day)2:00 am (next day)2:30 am (next day)3:00 am (next day)3:30 am (next day)4:00 am (next day)4:30 am (next day)5:00 am (next day)5:30 am (next day)6:00 am (next day)6:30 am (next day)7:00 am (next day) Add Hours
