New Accounts Form – Specialty Appliances

What type of practice/organization are you a part of?(Required)

Single Location Practice

Multi-Location Practice

Lab, University, or Other

To assist you better, please call 1-800-522-4636 or email newaccounts@specialtyappliances.com for more information. Thank you!

If a single location practice, are you a member of a DSO?(Required)

Yes

No

A DSO (Dental Support Organization) contracts with dental and orthodontic practices to provide critical business management and support including non-clinical operations. (Example: Smile Doctors, MB2 Dental, Tots to Teens) If you are unsure, please check with the doctor at your practice.

Name of DSO(Required)

DSO-Unique ID (Required for Elite Dental)

If a DSO, are you centrally billed?(Required)

Yes

No

Are you a member of a purchasing group?(Required)

Yes

No

Purchasing groups are member-based organizations that leverage purchasing power without having to meet predetermined volume requirements. (Example: Elite Dental Alliance, Schulman Group, Galler Group) If you are unsure, please check with the doctor at your practice.

Purchasing Group Name(Required)

Purchasing Group Unique ID(Required)

If a multi-location practice, are you a member of a DSO?(Required)

Yes

No

Name of DSO(Required)

DSO-Unique ID (Required for Elite Dental)

If a DSO, are you centrally billed?(Required)

Yes

No

Are you a member of a purchasing group?(Required)

Yes

No

Purchasing Group Name(Required)

Purchasing Group Unique ID(Required)

If a multi-location, within group are you centrally billed?(Required)

Yes

No

Central Billing Contact Name(Required)

First Last

Central Billing Contact Phone Number(Required)

Central Billing Statement Email Address(Required)

Central Invoice/Statement email box (if any)

Number of Locations(Required)

Practice Information

Practice Name	Practice Address	Actions

There are no Practices.

Practice Name(Required)

Practice Address(Required)

Street Address Address Line 2 City State ZIP Code

Practice Primary Contact Name(Required)

First Last

Practice Primary Contact Role/Title: e.g. Office Manager(Required)

Practice Primary Contact Email Address(Required)

Practice Primary Contact Phone Number(Required)

Billing Contact Name (if different from above)

First Last

Billing Address (if different than above)

Street Address Address Line 2 City State ZIP Code

Billing Phone Number (if different than above)

Billing Email (if different than above)

Doctor Information

Name	Area of Specialty	Actions

There are no Doctors.