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Co-Marketing Registration Form
Complete this form if you would like to be considered for AvaDent's Patient Accelerator Co-Marketing Program. Territories are limited and offered on a first-come, first-serve basis.
Name
*
First
Last
Address
*
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Website
*
Make sure you put in your full web address including the http://wwww.your domainname.com or https://www.yourdomainname.com
Email
*
Cell Phone
*
Type of Practice
*
Select One
General Dentist
Prosthodontist
Oral Surgeon
Periodontist
Multi-Specialty
Do you currently have an advertising budget?
*
Select One
Yes
No
If yes to the answer above what is the monthly ad spend
*
Do you offer any of these products (check all that apply)
*
Dentures
Partial Dentures
Removable Dentures (implant supported)
Fixed screw retained dentures 2 to 5 implants
How many offices do you have?
*
Select One
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21 or more
How Many AllonX or implant supported dentures (Pre-Covid19) did you place annually?
*
Select One
1 to 5
6 to 10
11 to 15
16 to 20
21 to 25
26 to 30
31 to 35
36 to 40
41 to 45
46 to 50
51 to 55
56 to 60
61 to 65
66 to 70
71 to 75
76 to 80
81 to 85
86 to 90
91 to 95
96 to 100
101 to 125
126 to 150
151 to 175
176 to 200
200 to 300
301 to 400
401 to 500
How do you produce your dentures & implant supported dentures?
*
Select One
In-House technician
External Lab
Would you like someone from AvaDent to contact you regarding the co-marketing program?
*
Select One
Yes
No
What is your status with AvaDent's Partner Program?
*
Select One
I'm currently a Partner
I would like more info on the Partnership
I would like to become a Partner
I'm not interested in becoming a Partner
Everything dentists need to capture and convert new patients.
Click Here for Your FREE 1-Hour Consultation ›
15730 North 83rd Way
Scottsdale, AZ 85260
United States
Tel.: Call 1-480-275-7144
Toll Free: Call 1-855-282-3368
Services
Complete Co-Marketing program
Communication & Sales Training
Review Management
All-on-X Infomercial
Custom Practice Videos
Virtual Consultations
AdWords Management
SEO Services
Hybrid Product Offering
Accelerset
All-On-X Hybrid w/integrated Bar
Snap Pin Denture
All-0n-X Hybrid
Overdenture
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