New Office Form "*" indicates required fields Step 1 of 2 50% First Name* Last Name* Practice Name* Dentist NPI #* Address Line 1* Address Line 2 City* State*AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificZip Code* Office Phone Number*HiddenZip Code*Please enter a number greater than or equal to 0.Dentist’s Cell PhoneEmail Address* Preferred Account Username* What Digital Impression System Does Your Practice Use?TriosMeditSironaIteroOtherNone First Name Last Name Who at the office should we speak with about patient scheduling? (Scheduling Contact Email) First Name Last Name Who at the office should we speak with about technical and case questions? (Technical Contat Email) First Name Last Name Who at the office should we speak with about billing? (Billing Contact Email) We send out all statements electronically. We will use the main email address to deliver statements, unless a billing address is specified. Communication is very important to our team. When you complete this form and send it to us, we log this information on your account. As always, we encourage you and your team to be open with our technicians. The best way to give us case feedback is here at the Dynamic Digital website. We appreciate the feedback to improve future cases.How did you hear about us? Statements are due in full net 30 from invoice date for cases. Products require payment to ship. If balance is not paid, the account is subject to a 1.5% finance charge per month of the unpaid balance. If not paid within 90 days, attorney fees, costs of collection, and continuing interest will be added.CAPTCHA Dentist Preferences "*" indicates required fields Step 1 of 4 25% Practice Name First Name* Last Name* Specialty Dentist NPI # Dentist Phone NumberEmail Address* Digital Die Spacer* None Light Medium* Heavy Items with asterisk are recommendedOcclusal Contacts* Heavy Medium* Tight Light Out of Occlusion Items with asterisk are recommendedOcclusion has insufficient reduction* Call me to discuss Adjust opposing tooth Adjust the prep and mark model / die Adjust the prep and make a 3D printed reduction coping (extra cost) If we need more occlusal clearance, how should we proceed?Interproximal Contact Design Preference* Tight – Fit to printed model Medium Light Broad Pin-point What strength and shape do you like your interproximal contacts? You can select more than one. Stain and Glaze PreferencesOcclusal Staining* None Light Medium* Heavy Color will be specific to the shade of the restoration. One with asterisk is recommended to look the most natural.Gingival Staining* None Light* Medium Heavy Color will be specific to the shade of the restoration. One with asterisk is recommended to look the most natural.Do you have any special instructions for our ceramicist?* Do you prefer Screw Retained or Cement Retained?* Screw Retained Cement Retained Screw Retained is most requested with the increased strength and esthetics of the new generation zirconias.For custom abutments, do you prefer to have the margin above or below the tissue?* Above Below Typically below the tissue but we can place it where you would like.What materials do you prefer in the anterior?* High-Esthetic Zirconia High-Strength Zirconia Pressed eMax We do not offer PFM restorations.What materials do you prefer in the posterior?* High-Esthetic Zirconia High-Strength Zirconia Pressed eMax We do not offer PFM restorations.How do you handle tissue management?* Stock Healing Custom Healing Tissue Former None Are you using any provisionals to control tissue countours?CAPTCHA
