Teeth-N-Stuff

Dental Prosthetic Solutions
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Please fill out the form below to recieve your starter package. Please specifiy any special requests, questions or comments at the bottom of the form. If you do not have time to fill out this form online, you may download and print a copy so you can fill it out and fax it at your convenience.

New Client Form (.pdf) (Adobe® Acrobat® Reader required; free download at www.adobe.com)

Contact Information:    
First Name (Dr) Last Name I like to be addressed as:
License Number State Of License  
 
Please check all that apply:
DDS
DMD
DDM
MS
MSD
MD
APC
EDD
PhD
INC
Dental Alma Mater
Year
     
Practice Address #1
Suite
City
State
Zip
Phone Number
Fax
E-Mail

Practice Address #2
Suite
City
State
Zip
Phone Number
Fax
 

Main Contact for Case Info
Position/Title
Contact Phone
Please Send Cases To:
Address #1
Address #2
Case Specific
Always
     
Doctor's Main Phone
Alternate Phone
 
Doctor's Main Fax
Doctor's Main E-mail
Specialty/Focus/Area of Expertise
Primary Need in Removable Work
Primary Shortcoming of Present Laboratory

Credit Information:
Supplier/Vendor #1
Phone
Supplier-Vendor #2
Phone
Dental Laboratory #1
Phone
Dental Laboratory #2
Phone
I will pay by check
I always pay by credit card
I can pay via PayPal©

Other:

If you have any requests for prescriptions, special needs, questions, comments, etc. please tell me about them in the space below:

  © 2004 Steve Geib