DENTIST PROFILE ENTRY FORM

Please complete the form below with the details that are most valuable for attracting and growing your patient base.

*Full name Gender   Female ✔    Female ✔

  Male ✔    Male ✔ Degrees and designations   DMD ✔   DMD ✔   DDS ✔   DDS ✔   MD ✔   MD ✔   MAGD ✔   MAGD ✔   FAGD ✔   FAGD ✔

Specialty   General Dentistry ✔   General Dentistry ✔   Prosthodontist ✔   Prosthodontist ✔   Endodontist ✔   Endodontist ✔   Orthodontist ✔   Orthodontist ✔   Pediatric Dentistry ✔   Pediatric Dentistry ✔   Oral and Maxillofacial Surgery ✔   Oral and Maxillofacial Surgery ✔ Dental practice name The year you started or joined your current dental practice Office ZIP Code During the same appointment slot, do you typically work with one patient or more than one patient at a time?   One patient ✔    One patient ✔   More than one patient ✔    More than one patient ✔ Which insurance companies are you contracted with?   Aetna ✔   Aetna ✔   Anthem/BCBS ✔   Anthem/BCBS ✔   Cigna ✔   Cigna ✔   Delta Dental ✔   Delta Dental ✔   Guardian ✔   Guardian ✔   Metlife ✔   Metlife ✔   United Healthcare ✔   United Healthcare ✔   Medicare ✔   Medicare ✔ What advanced technology and high-tech tools do you use in your practice?   Intraoral Camera ✔   Intraoral Camera ✔   Cone Beam CT ✔   Cone Beam CT ✔   3D Microscopes ✔   3D Microscopes ✔   Digital X-Rays ✔   Digital X-Rays ✔   Digital Impressions (3-D Intraoral Scanner) ✔   Digital Impressions (3-D Intraoral Scanner) ✔   Carivue Digital Caries Detection ✔   Carivue Digital Caries Detection ✔   Dental Lasers ✔   Dental Lasers ✔   Cerec One-Visit Crowns ✔   Cerec One-Visit Crowns ✔   Dental Magnification Loupes ✔   Dental Magnification Loupes ✔   Ultrasonic Instrumentation ✔   Ultrasonic Instrumentation ✔   Digital Smile Design (DSD) Application ✔   Digital Smile Design (DSD) Application ✔   3D Printing ✔   3D Printing ✔   CAD/CAM ✔   CAD/CAM ✔   Virtual Reality (VR) Tool ✔   Virtual Reality (VR) Tool ✔   Robotics ✔   Robotics ✔   Artificial Intelligence (AI) ✔   Artificial Intelligence (AI) ✔   Airflow Master Air-Abrasion ✔   Airflow Master Air-Abrasion ✔ What methods your practice offers for patients to communicate with your team, schedule visits, and access their dental information?   Online chat ✔   Online chat ✔   Appointments booking online ✔   Appointments booking online ✔   Appointments booking by phone ✔   Appointments booking by phone ✔   Text messaging ✔   Text messaging ✔   Online patient forms ✔   Online patient forms ✔   Patient portal ✔   Patient portal ✔   Video calls ✔   Video calls ✔ What comfort features do you offer your patients during their visits?   Oral Conscious Sedation ✔   Oral Conscious Sedation ✔   Freshen up wipes ✔   Freshen up wipes ✔   Body heat mat with gentle massage ✔   Body heat mat with gentle massage ✔   NuCalm ✔   NuCalm ✔   iPad to listen or watch ✔   iPad to listen or watch ✔   i-glasses to watch movies ✔   i-glasses to watch movies ✔   Warm soft blanket ✔   Warm soft blanket ✔   Comfy wrap around neck ✔   Comfy wrap around neck ✔ Any additional information you'd like to include on your profile for prospective patients, such as promotions, blogs, or videos?

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