IndepenDENT Dental Solutions | A Dental Purchasing Group

IDS Membership Application

Practice Name: *

Name & Role of the Person Completing the Application: *

Email of Person Completing the Application: *

Your Preferred IDS Password: *

Primary Doctor's Information

Doctor's First Name: *

Doctor's Last Name: *

Doctor's Email Address: *

ADA Number

State License No. *

License State: *

License Expiration Date: *

Are you an ISDS Member? *

Office Address

Practice Street Address: *

Suite, Unit or PO Box Number:

City: *

State: *

Zip Code: *

Country: *

Practice Phone Number: *

Add Office Location Remove Office Location

Office Manager and/or Ordering Assistant's Contact Information

Ordering Assistant's Name: *

Ordering Assistant's Email: *

Same as Doctor's Office

Phone

Email

Account Information

How would you like your account setup? (For multiple locations only)

1 Account # with Multiple Ship-tos (Good option for a single ordering person and centralized finances)

One Account per Location (Good for practices that operate independent at each location)

Referral Information

If you met us at an event, please let us know which event in the field below:

Other Comments

Terms and Conditions

MSA *

I agree to the terms and conditions in the Member Services Agreement

IDS Member Services Agreement (MSA)

Signature *

Text

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