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Please tell us how to contact you...
If you are from outside the continental United States please call us at +1 480 275 7144
First Name
*
Last Name
*
Mobile Phone Number
*
How did you hear about us?
*
Google Search
Bing Search
AGD Meeting
CDA Meeting
Friend
AAID Meeting
ACP Meeting
AO
Email
Facebook
Instagram
LinkedIn
CBS
NBC
MSNBC
Direct mail piece
Email Address
*
Confirm Email Address
*
Is the address below the same as your shipping address?
*
YES
NO
Legal Business Name:
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Street Address
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Suite Number
City
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State
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Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Washington DC
Zip/Postal Code
*
A little bit about your business and your needs...
Type of business
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Dental Lab
General Dentist
Implantologist
Oral Surgery
Periodontist
Prosthodontist
How many offices do you have?
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1
2
3
4
5 or more
Do you own a scanner
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Yes
No
Types of procedures you offer (select all)
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Dentures
Overdentures
Fixed Dentures
Do you have a CBCT in your office?
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YES
NO
NO, but I have room for one.
Est. number of dentures, overdentures or hybrids you make each month?
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1 to 2
3 to 5
6 to 10
10 or more
Do you place and restore dental implants?
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YES, I place and restore implants
NO, a specialist does this for me
Do you have chairtime for more procedures?
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YES
NO
Would you be interested in getting more full arch cases?
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YES
NO
Are you interested in getting more dental implant patients?
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YES
NO
When we ship, where do you want it to go?
Business Name:
*
First Name
*
Last Name
*
Street Address
*
Suite Number
City
*
State
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Washington DC
Zip/Postal Code
*
Thank you for joining the AvaDent Family!