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Full Listing Registration Form

To join the Dentistinfo.com World Wide Web listing service:

Complete the Home Page Creation Form below in full. Press the submit button at the bottom of this page to submit the application form. Mail a copy of your current dental and/or specialty license to the address at the bottom of this page. Click on the PayPal button after you submit your form to pay at the PayPal site, once completed you will be returned to our site.

Your name, address and phone number will be entered into our database and will be searchable but will only appear in our Dentist Search Results Page which shows summary information only.
Upon approval, your full home page will be accessible to the world.

Home Page Creation Form

Select one:

Is this an update of an existing listing? No Yes

Name

D.D.S. D.M.D. M.D. Ph.D. M.S.

Practice Name

Address

City                       State (2 letter abr.)

Zip Code

Phone                            Fax

E mail

Additional cities in which I would like to be searchable

Additional zip codes in which I would like to be searchable

Add my link. My URL:

Hours:

Mon	Tue	Wed
Thur	Fri	Sat
	Sun

I am human - what is 3plus6

Nearest Intersection
Degree(s) received from:
Year(s)
Continuing Education:

Membership in the following?

Will you be sending a logo or picture?No Yes

Select the following Services Provided:
(These will be searchable)

	Crowns, Bridges and Dentures (Prosthodontics)
	Root Canals (Endodontics)
	Extractions Oral Surgery)
	Gum Treatments (Periodontics)
	TMJ
	Children (Pedodontics)
	Bleaching, Veneers and Bonding (Cosmetic Dentistry)
	Implants
	Braces (Orthodontics)

that is open on Saturdays or Evenings

welcomes 24 Hr. Emergencies

that uses 90% less radiation (Digital X-rays)

Select all that apply (16 Items)

(You may need to hold the Ctrl or
Command button to select more than one)

Profile:

Personal Information (Will not appear on Webpage)

Please indicate if you have ever...
No Yes ...been convicted of a felony?
No Yes ...had your dental license placed on probation or suspended?
No Yes ...been sued for malpractice?
No Yes ...been brought up for peer review?
No Yes ...surrendered or had your State or Federal Controlled subst. license placed on probation, revoked or suspended?

Dental license number:
Years in practice:

To the best of my knowledge, all of the preceding answers and information provided are true and correct. If I ever have any changes, I agree to advise Dentistinfo as soon as possible.

I would like to pay for the following period:
1 Year ($49.95)

Payment Method:

The safer, easier way to pay.

After receiving completed form, Dentistinfo.com reserves the right to reject or edit all applications based on our ethical standards. If editing is required you will be notified.