Your Name
Practice Name
Specialty
Year of Graduation
Year Completion of Residency
Do you perform Third Molar Extractions YesNo
If yes, ERUPTED, PARTIALLY IMPACTED or FULLY IMPACTED?
ERUPTEDPARTIALLY IMPACTEDFULLY IMPACTED
Do you perform dental implants? YesNo
If yes, which do you perform the surgical placement?
the implantprosthetic/restorative component
What type(s) of Sedation do you offer your patients, please describe
Have any claims been made against you? YesNo
If yes, please describe
Current Insurance Company
Claims Madeor Occurrence
Retro Active Date:
Phone
Email
Location Address
City
Zip
County
State
What is your preferred contact method? PhoneEmail
If phone, what is the best time to call?
Please leave this field empty.
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