Send Us Your Digital Files and Get a Rebate On Your Lab Bill!

Doctor Name *

First Name

Last Name

Phone Number *

(###)

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Alternate Phone Number

(###)

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Fax Number

(###)

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Office Days *

M

T

W

Th

F

Dual Offices *

Yes

No

Type of Business *

Sole Proprietorship

Partnership

Corporation

LLC

Doctor Preferences *

I will attach my completed Doctor Preference Form here

I will email my completed Doctor Preference form to x.email.com later.