PDA Productivity Bundle Sale
For our September Workshop
Let’s get you registered.
Practice Information
Practice Name*
Primary Doctor's Last Name*
Please enter the preferred person to contact if we have questions and to coordinate registration.
Preferred First Name*
Preferred Last Name*
Preferred Email Address*
Practice Phone*
Practice Street Address*
City*
State*
Postal Code*
Number of Locations*
Average Monthly Production*
Number of Doctors*
Number of Active Patients*
0 - 500
501 - 1000
1001 - 2500
2501 - 3500
3501 - 5000
5000+
How did you hear about us?*
None
AAOSH
Bruce
CEREC Email Blast
Compassionate Finance
Current Client
Darby Dental
Dental Intel
Dental Town
Dental Whale
Dental Advisors
DEW
Email/Newsletter
Google Search
Mommy Dentist In Business
PDA Event
PDA Main Website
Podcast
Referral - PDA Team
Referral - Other
Returning Client
Trade Show
Webinar
Other
Attendees
1
1 Doctor and PDA On Demand
:
$2195.00
per
1
2
3
4
5
6
7
8
9
Additional Doctors
:
$2195.00
per
1
2
3
4
5
6
7
8
9
Associate Doctors
:
$1495.00
per
1
2
3
4
5
6
7
8
9
Hygienists
:
$1295.00
per
1
2
3
4
5
6
7
8
9
Dental Assistants
:
$1295.00
per
1
2
3
4
5
6
7
8
9
Admin Staff
:
$1295.00
per
Payment Information
Credit Card
(3% card transaction fee)
Credit Card Number
Expiration Month/Year
01
02
03
04
05
06
07
08
09
10
11
12
/
21
22
23
24
25
26
27
CVV/CSC
Name on Credit Card
Street Address
City
State/Province
Postal Code
Country
United States
Canada
Phone
ACH/eCheck
Account Type
Business Checking
Checking
Savings
Account Number
Bank Routing Number
Account Holder Name (First and Last)
Bank Name
Phone
Total:
$
2195.00
I wish to make monthly payments of $
.
Terms & Conditions
Cancellation is accepted up to 30 days prior the program start date. Refunds will incur a credit card cancellation fee. There is a 3% transaction fee for card payments. There is a $100.00 fee for any monthly payment option.
I agree to these Terms & Conditions*
Processing Your Registration
Yay - Success!
Your registration was successfully processed and you should receive a confirmation via email. We will reach out to you for additional details as needed.
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