Diamond Club Makers Application - Diamond Club Makers

"*" indicates required fields

Please answer all in full.

This will be used to tell if I can help you. It is important to me that I can really help you.

Name*

First Last

Cell Phone*

Office Phone*

Email*

Age*

Are you on WhatsApp yet?*

Yes

How Many Years Have You Been Practicing?*

Practice Information

Practice Name*

Are you a:*

How many Associates do you have?*

How many partners do you have?*

How many offices do you have?*

Do you have any affiliation with a DSO/Corporate Partner or other corporate entity besides your non-corporate office?*

Yes

Are you in negotiations or considering any affiliation with a DSO/Corporate Partner?*

Yes

Practice Location*

Street Address City State / Province / Region ZIP / Postal Code Country

Number of Hours the Practice Treats Patients in a Week*

Number of Dentists*

Number of Staff*

Number of Chairs*

Last three years total practice collection numbers?*

Last Year

Two Years Ago

Three Years Ago

Invisalign case start numbers in the last year?*

Last three months Invisalign case start listed per months?*

Previous Month

Two Months Ago

Three Months Ago

Average new patients a month your practice sees*

Clincheck ID#1

Clincheck ID#2

Clincheck ID#3

Maximum of 3. Find your Clincheck ID # on the Invisalign Doctor Website (which can be accessed from your phone at this link) Then press ‘Account’ ‘Payments’ and you will see you ID# which is shown in pink highlighter. Visit Invisalign Doctor site.

What Invisalign Advantage level are you currently at?*

Are you about to enter a significant life changing period in your life or in your practice?*

If so, what?*

Are you or about to be an instructor/teacher/coach/mentor for any dental organizations/companies/groups or similar?*

Yes

If so, which one?*

Finally, and most importantly, why you want to do more Invisalign?*

How did you hear about us?*

Align Rep Name*

First Last

Current or Past DCMer Name*

First Last

Other (specify)*

Hidden

Payment Method*

Application Fee*

The next class is being planned for December of 2022 or January of 2023. We are currently accepting applicants for the waiting list. Upon submitting this application, you will be charged a $1 non-refundable fee. If you are accepted to the class you will be asked to complete the full payment of $9,479.

Application Fee

Price: One Dollar

Name

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