New Client Information


New Client Information
To help us better serve you now and in the future, please provide the information below.
Referred By
Practice Name
Dr. Name
FirstLast
Office/Shipping Address
Office Phone
Office Fax
Billing Address
If different from above
Email - General Office
Email - Doctor‘s
Dr. Cell phone
(if unavailable in office or by email)
Please do not contact me via cell phone or email. Wait until next business day to contact office, even if it will fail to meet requested deliver date.
Shipping Days that office is closed?
  Mon   Tue   Wed   Thu   Fri   Sat
Person responsible for payables
All new accounts must guarantee payment by keeping a current credit card on file.
Credit Card #
  Visa   MC   AMEX Exp. Date
Other Information
Financial Policy

In our continued commitment to provide the highest quality service to all our clients and to have those services comfortably affordable, we are pleased to offer you these options for payment.
Please indicate which option will work best for your practice:



I agree to have monthly charges auto billed to credit card VISA, Mastercard, or American Express.
       
  Visa   MC   AMEX
Credit Card #
Exp. Date CCV code (on back)
Preferred Monthly Date for charges to be run
       
I agree to be billed on 30 day terms. All invoices are due net 30 days from date of invoice. Balances not paid within 30 days are subject to a delinquency charge. Accounts that become 45 days past due will be placed on C.O.D. plus a portion of the remaining balance with each case delivered thereafter until balance paid in full.


Two (2%) per month interest (24% per year) will be charged on accounts 45 days or more delinquent. New accounts with a valid credit card on file will be granted a maximum $5000 monthly credit limit. Should the limit be exceeded, payment will be required to clear the account to fabricate additional cases. Larger credit limits can be approved, by contacting Diane Bruce at 480.968.6131 in advance.



To submit online documents securely, an access code and postal code will be required.
Postal Code
A private access code will be automatically be generated for you after submission of this form.
 
Doctor‘s Signature


Client Preferences
1.What problems have you typically had with other labs?
  Shade  
  Contacts  
  Margins  
  Occlusion  
  Fit  
  Contour  
  Anatomy  
  Service  
  Other  
2.Preferred Occlusal contact with opposing teeth?
 a.Positive Contact  
 b.Foil Relief  
 c.Out of Occlusion  
3.What kind of impression material do you use?
 
4.What articulator system do you use?
 
5.What are your office hours?
 
6.What team members would you like us to communicate with regarding case details , due dates, materials etc?
 
7.What specifically about Gold Dust made you choose us for your next case?
 
8.Any specific Continuing Education experience that you would like us to be aware of?
 
Additional Comments