IDC Intake Form

Company Name *

Address Line 1 *

Address Line 2

City *

State *

Zip Code *

Country *

File Upload

Maximum upload size: 52.43MB

Website *

Primary Contact *

First Name

Primary Contact Last Name *

Last Name

Phone Number *

Email *

Please select the category(s) that best describes your company's service(s):

Members will be able to filter by category to narrow their search

Other

Keywords *

Please add keywords that describe your services (i.e. Credit Card Processing, Insurance, Supplies, Implants)

3 - 5 bullet points that describe your service(s) *

These bullet points will be the quick overview next to your logo

Description of advantages for IDS members *

This will be behind a member login, so only members can view. Please outline the special offers & advantages of the partnership

Contact form URL for interested members

If applicable, please provide a URL where our members can submit their information if they are interested in your service(s)

Email for interested members

If you do not have a contact form and would prefer an email, we can have an email automatically sent to you with the member's information.

Upload linked marketing document (need file upload)

If you would like to link a marketing document to your profile, please upload here. If you have multiple, please send to [email protected]

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