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Information Request
First name
Last name
Address
E-mail address
Degree Type
(please indicate if specialty)
Years in practice
Practice type
.......Select options.........
solo practitioner
group practice ( general dentistry )
group practice ( specialty )
group practice (general and specialty)
Number of locations
Please list practice
management software
Please rate your computer experience level (from 1 - 10)
.......Select options.........
1
2
3
4
5
6
7
8
9
10
Please indicate current patient charting method
paper
practice management
clinical component
please rate if paperless
How??
.......Select options.........
1
2
3
4
5
6
7
8
9
10
other (please describe)
If you are not employing a "paperless" charting system, have you attempted to in the past? Please explain your experience
general remarks / questions
opt-in for mailing list
Yes
No
opt-in to be contacted
by a representative
Yes
No
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