For more information on proper packing techniques and how to fill out RX's Click Here
How did you hear about us?
Provide more information (Who referred you to our lab or which trade show) below:
| General Information |
Doctors Name:
License number & Expiration:
Practice Name:
How many office locations?:
Practice Location:
City:
State & Zipcode:
Phone Number:
Email Address:
| Office Contacts |
Billing Contact & Phone Number:
Appliance Contact & Phone Number:
Shipping Address:
Shipping Address #1:
Shipping Address #2:
List any doctors submitted cases to our lab from this practice:
License number # Expiration:
Please provide your office hours:
How would you like to receive your billing information?:
Payment Policy: Invoices are mailed or emailed on the 1st business day of every month. Payments are due before the 15th of the month in which you received the invoice (You receive the invoice on July 1st payment should be received by July 15th). Please see our full billing and payments policy under our "About us> Billing and Payments Policy" section of our website.
What type of payments are accepted?: We accept checks via mail or E-Check. Your account can also be setup for automatic withdrawl via ACH on the 1st or the 10th of every month.
Thank you for taking the time to fill out this form, please sign below to state you have read and understand our billing and payment policy.