Personal/Practice Information:

First Name *

Last Name *

City *

State *

Zip Code *

Phone Number *

Email Address *

Country *

Are you currently a certified Invisalign provider? *

Enter DID (Access your DID by logging into the Invisalign Doctor Site: All numbers from the Invisalign Doctor Site in the upper right-hand corner in parentheses below your name and next to your practice name.) *

Please indicate your role in the practice *

How many associates operate in your practice? *

How many years have you been in practice? *

Are you affiliated with a DSO? *

What DSO are you affiliated with? *

Treatment and Practice Background

Are you currently treating with clear aligners? *

What brand do you use? *

Estimated number of monthly cases? *

Do you have a digital scanner(s)? *

What brand of digital scanner? *

How many scanners do you have? *

How many hygiene chairs do you have in your practice? *

How many operatories do you have in your practice? *

Roughly how many active patients does your practice see each year? *

How do you accept payment from patients? *

Non-Disclosure Agreement (NDA): By checking "I agree", the undersigned agrees to maintain the confidentiality of any pricing discounts received from Seattle Study Club or Align Technology and will not disclose such discounts to any third party without prior written consent from Seattle Study Club or Align Technology. This obligation of confidentiality shall remain in effect indefinitely from the date of disclosure of the discounts. *

I agree

Professional Memberships

What professional memberships are you associated with? *