**Please note that this is a sample application with only some of the questions asked of each applicant. When applying, additional information may be required.**
1-800-DENTIST® Member Application
(for primary dentists only; additional dentists must complete associate application)
Name of applicant dentist: DOB: / / Gender: ☐ M ☐ F
Name of practice (if different):
Practice address: Cross-street:
City: State: ZIP:
Phone: Fax:
Cell phone: E-mail:
Practice Web site:
Number of dentists (including yourself): Number of operatories:
Associate or other dentist name(s) (if applicable):
Associate or other dentist names(s):
Associate or other dentist name(s):
(When applying, you will need to acknowledge in writing that Associate(s) will not see any FD potential patients until approved.)
Specialist(s) in office: ☐ endo ☐ ortho ☐ pedo ☐ perio ☐ prostho ☐ oral surgeon
(When applying, you will need to provide copies of certification of specialty, as well as sedation/anesthesia permits, if applicable.)
Is there someone we can thank for referring you?
Have you ever been a member of Futuredontics? If yes, when?
Dental degree: School: Year:
Specialty: School: Year:
Additional training: School: Year:
Years in practice at your current location:
List all dental associations of which you are a member (please spell out):
Primary dental license number? ADA membership #
In which other states have you held a dental license? (List state(s) and license #s)
Are you licensed under or have you practiced under any other name?
☐ yes ☐ no
Has your license ever been denied or revoked?
☐ yes ☐ no
Have you ever been convicted of a felony?
☐ yes ☐ no
Have you ever been subject to peer review or any discipline (i.e. probation, suspension)?
☐ yes ☐ no
Have you ever had any complaints filed against you with the state licensing board?
☐ yes ☐ no
Have you or has your corporation ever been sued for malpractice?
☐ yes ☐ no
Were you ever denied authorization to be a provider for federal/ state Medicaid?
☐ yes ☐ no
Has your federal/state controlled substance registration/license ever been subject to discipline or been surrendered or has an application been denied?
☐ yes ☐ no
When applying, you will need to provide a written and signed explanation for all "yes" answers above, including date, case number, reasons and outcome of action. Again, please note that this is only a sample application and that additional information may be required.
**Member profiles are used to educate consumers about all the conveniences and features of your practice so that they feel comfortable choosing to be referred to you. Please note that these are only some of the questions we ask to complete your profile when you become a member.**
Member Office Profile
Which services do you normally provide on a new patient's first visit? (check all that apply)
☐ examination ☐ no-charge ☐ low-charge ☐ FMX ☐ prophy
Are you available nights, weekends or other extended/emergency hours?
☐ yes ☐ no
Which conveniences do you offer to ensure a pleasant patient experience? (headphones, TVs, etc.)
Who in your office performs prophys?
☐ dentist ☐ hygienist ☐ both
If you treat children, what accommodations do you offer to make them comfortable? (play area, videos, etc.)
Does your practice meet OSHA standards?
☐ yes ☐ no
Do you offer free/validated parking?
☐ yes ☐ no
What type(s) of anesthesia/sedation do you provide? (check all that apply)
☐ IV (in hospital) ☐ local anesthesia ☐ oral sedation ☐ nitrous oxide
☐ needleless/electronic anesthesia (H-Wave, Wand, etc.) ☐ other:
☐ IV (in office) (If yes, you must provide sedation permit for sedation provider to list this on your profile.)
What cosmetic treatment does your practice provide? (check all that apply)
☐ bonding ☐ porcelain veneers ☐ tooth whitening ☐ Supersmile
☐ whitening: in-office ☐ Lumineers® ☐ da vinci veneers ☐ MACVENEERS
☐ BriteSmile ☐ Opalescence ☐ Rembrandt ☐ Zoom!
☐ Crest Whitestrips ☐ Day White ☐ Trèswhite ☐ GoSMILE
☐ Nite White ☐ Nu Radiance ☐ other:
What root canal therapy do you provide? (check all that apply)
☐ limited root canal therapy ☐ single-visit root canal ☐ molar endodontics ☐ none
What languages, if any, are spoken in the office (other than English)?
What laser therapy does your practice provide? (check all that apply)
☐ for cavities ☐ for fillings ☐ periodontal treatment ☐ whitening ☐ Waterlase
☐ other:
What oral surgery treatment does your practice provide? (check all that apply)
☐ implants - surgical aspect ☐ microsurgery ☐ simple extractions
☐wisdom teeth: impacted ☐ wisdom teeth: non-impacted ☐ Nobel implants
☐ other implants:
What orthodontic treatment does your practice provide? (check all that apply)
☐ adults ☐ braces (types): ☐ children ☐ retainers
☐ Invisalign ☐ non-surgical bite correction ☐ none ☐ other:
What periodontic treatment does your practice provide? (check all that apply)
☐ laser periodontal treatment ☐ non-surgical gum treatment ☐ periodontal surgery
☐ root planing ☐ scaling ☐ Arestin ☐ diode laser - soft tissue
What restorative treatment does your practice provide? (check all that apply)
☐ amalgam fillings ☐ bridges ☐ composite fillings ☐ crowns ☐ denture repair
☐ full dentures ☐ inlays ☐ onlays ☐ implants - restorative aspect
☐ partials ☐ Nobel "Teeth in an Hour" ☐other:
What sterilization techniques does your practice use? (check all that apply)
☐ disposable handpieces ☐ protective clothing, goggles ☐ spore testing
☐ state-of-the-art sterilization ☐ sterile handpieces and instruments ☐ other:
What special needs patients do you treat? (check all that apply)
☐ mentally disabled ☐ physically disabled ☐ wheelchair access ☐other:
What special technology does your practice offer? (check all that apply)
☐air abrasion (KCP, etc.) ☐ CEREC ☐ DIAGNOdent ☐ halimeter (halitosis)
☐ digital radiography (low radiation, CDR, etc.) ☐ digital tomography ☐ intraoral camera
☐ imaging (treatment planning-computerized "after" photos) ☐ interactive patient education system
☐ panoramic X-ray ☐ prophy jet ☐ state-of-the-art equipment ☐ ultrasonic cleaning
☐ other:
What other clinical services does your practice offer? (check all that apply)
☐ acupressure ☐ bruxism ☐ sealants ☐ fresh breath ☐ halitosis treatment ☐ TMD
☐ BreathRx ☐ house calls ☐ hypnosis ☐ lab on site ☐ limited lab on site ☐ CPR
☐ laser treatment for snoring ☐ athletic mouthguard ☐ night guard ☐ Silent Nite
☐ NTI appliances ☐ pain management ☐ sleep disorder ☐ smoking cessation /p>
☐ snore guard ☐ other:
Member represents and warrants that any information provided by or on behalf of Member as to the products, brands and services identified above is accurate and that Member is authorized to provide and does offer and provide the products, brands and services identified or to be identified in Member's profile.
For questions about this sample application
or for more information about how to become a
1‑800‑DENTIST member, call 1‑888‑732‑2429.
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