Copyright 2013 - Allsman Dental Arts, Inc. - All Rights Reserved
E-mail: info@allsmandentalarts.com
New Account Application
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Doctor Information
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Title:
Corporate Offices/Partners
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Business References
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What positive experiences have you had with dental laboratories in the past?
How Can We Help?
What negative experiences have you had with dental laboratories in the past?
What type of relationship do you expect to have with your laboratory?
Special Instructions for
Crown & Bridge Cases
Occlusion (EX: Out of Occlusion .5mm):
Special amounts of dye spacer (Normal is 2 coats):
Interproximal contacts (EX: Broad):
Additional Preferences:
Insuficient Occlusal Reduction:
If other please explain:
Account Authorization & Agreement
The undersigned agrees to the following: Terms are net 30-days from the statement date. A 2% per month finance charge will be assessed on all past due accounts. Cases will be shipped C.O.D. prior to credit approval. In the event an account is not kept current, the undersigned agrees to pay all legal fees and court costs involved in collection activities, and agrees for the hearing to be held in the state of Utah.
Who Should We Contact With Questions
Technical:

Shipping Dates:

Billing:

How would you prefer to be contacted?
By typing your name in the box below you are electronically signing this form and agree to the above Account Autorization & Agreement.
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