"*" 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 (MUST be at least text capable and ideally WhatsApp capable)*Office Phone*Email* Age* Are you on WhatsApp yet?* Yes No How Many Years Have You Been Practicing?* Practice InformationPractice Name* Are you a:*Single DentistPartnerDSO/Corporate PartnerHow many Associates do you have?*None1234+How many partners do you have?*None1234+How many offices do you have?*123-55+Do you currently or prior have any affiliation with any DSO/Corporate Partner, Invisalign buying group, or other corporate entity besides your non-corporate office? ( Failure to divulge any affiliation is grounds for dismissal without refund)* Yes No Are you in negotiations or considering any affiliation with a DSO/Corporate Partner ?* Yes No Practice Location* Street Address City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Number of Hours the Practice Treats Patients in a Week* Less than 2020212223242526272829303132333435363738394041424344454647484950515253545556575859606162636465666768697071727374757677787980 or aboveNumber of Dentists* 123456789101112131415161718192020+Number of Staff* 1234567891011-2021-3031-4041-5051-6061-7071-8081-9091-100100+Number of Chairs* 1234567891011-1516-2021-2526-3031-3536-4041-4546-5050+Last three years total practice collection numbers?*Last YearTwo Years AgoThree Years AgoInvisalign case start numbers in the last year?* Last three months Invisalign case start listed per months?*Previous MonthTwo Months AgoThree Months AgoAverage new patients a month your practice sees* 1-1011-2021-3031-4041-5051-6061-7071-8081-9091-100101-110111-120121-130131-140141-150151-160161-170171-180181-190191-200200+Clincheck ID#1Clincheck ID#2Clincheck ID#3Maximum 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?* Bronze - 0 points (less than 5 cases/6mo)Silver - 5000 points (5+ cases/6mo)Gold - 24000 points (24+ cases/6mo)Gold+ - 35,000 points (35+ cases/6mo)Platinum - 65,000 points (65+ cases/6mo)Platinum+ - 100,000 points (100+ cases/6mo)Diamond 1% - 140,000 points (140+ cases/6mo)Diamond+ 1% - 200,000 points (200+ cases/6mo)What is your highest Invisalign Advantage level achieved? Are you about to enter a significant life changing period in your life or in your practice?*Choose OneYesNoIf so, what?*What is the name and phone number of your Invisalign Rep?Align rep name Align rep number Are you or about to be an instructor/teacher/coach/mentor for any dental organizations/companies/groups or similar?* Yes No If so, which one?*Finally, and most importantly, why you want to do more Invisalign?*How did you hear about us?*Select OneAACA GRCAlign GP SummitCurrent or Past DCMerAlign RepDCM websiteAACA JournalAACA Wednesday WebinarOtherAlign Rep Name* First Last Current or Past DCMer Name* First Last Other (specify)* HiddenPayment Method*Credit CardApple PayGoogle PayApplication Fee*Classes start every January and July. But are formed prior. Applying early increases your chance of being accepted for the next available class. Your responses should be complete, honest, and accurate. There is a $1 fee (non-refundable). If you are accepted to DCM, you will be asked to complete full payment. At this time that is $10479 for entry to six months of the DCM program.Application Fee Price: $1.00 Please use a MasterCard or Visa instead. Amex is not accepted. Thanks!NameThis field is for validation purposes and should be left unchanged.