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Clinic's details
Clinic's name
Contact name
Clinic's phone number
Contact phone number
Address line 1
Address line 2 (Optional)
Address line 3 (Optional)
City / Town
State / Province / Region
State is a required field
Zip / Postal code
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Australia
Canada
Denmark
Finland
France
Germany
Italy
New Zealand
Norway
Spain
Sweden
United Kingdom
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Other
Country
Clinic is part of a Dental Service Organization (DSO)?
Yes
No
Clinic uses an intraoral scanner?
Yes
No
Scanner model:
Doctor's details
First name
Last name
Email address
Phone number
Provider Identifier(s)
Identifier Type
Identifier #
NPI
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Unique ID License
Please enter a valid Unique ID License
AHPRA
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Health Provider Index
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Add identifier
Provider identifier is a required field
Identifier Type
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NPI
Unique ID License
AHPRA
Health Provider Index
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Doctor is an orthodontist?
Yes
No
Products I'm interested in?
Products of interest? is a required field
Have you attended a Filtek™ Matrix Hands-On Workshop?
Yes
No
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