Divine Dental Studios

 

Doctors Information Sheet

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    Ownership
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    At present location since
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    Year Established
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Price Related Information

1. Please designate a contact person in your practice that will handle the ongoing relationship with Divine Dental Studios:
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2. Please indicate the practice’s business hours by designating the times the practice is open during a normal work week:
    Mon
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Tue
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Wed
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Thu
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Fri
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Sat
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3. In case we need to reach you about a specific case, and you are not in your office, please designate two alternate telephone numbers where you may be reached. (We will only use this contact method as a last resort):
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4. Please indicate the company you prefer to ship your cases with from the following options
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5. Please indicate if your shipping address is different from your billing address. If this does not apply to you please skip to the next question.
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6. Please indicate the publications you read on a regular basis:
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7. Please indicate the conventions, conferences, and/or seminars you are planning on attending in the coming year:
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Lab Relationship Information

8. In order to plan ahead and be able to allocate your units to a specific technician in the lab to ensure that you get a consistent quality of work from Divine Dental Studios, we want to get a sense of the overall number of fixed laboratory fabricated units you create in a month. Please give us an estimate of this quantity.
    a)  Number of laboratory units fabricated
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9. In order to ensure that we are able to meet the turnaround times required to meet your needs please indicate the average number of business days your staff schedules between a crown prep appointment and a crown seat appointment:
    
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10. Please indicate which type of laboratory fabricated restorations you prescribe. Please allocate the units you send to labs, by percentage, across the following categories. Please be sure that they total 100%.
    a)  Indirect composites %
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    b)  Porcelain fused to metal (PFM) %
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    c)  All ceramic restoration %
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    d)  Pressables %
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    e)  Other Restorations %
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11. In order to ensure we use the appropriate means to communicate with you, please tell us the various methods you use in communicating with your dental lab. Please rate each of the following communication methods on a scale of 1-10 (10 = highest), as to each method’s overall effectiveness in working with your lab.
    a)  Email
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    b)  Fax
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    c)  In-person
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    d)  Mail
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    e)  Phone
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    d)  Web Site
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    e)  Other
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12. In order to track our success in our relationship from the beginning, we want to understand the type of dental labs you currently use. Please allocate the percentage of units which you send to each of the following types of labs segmented in terms of the cost per unit to you. Please be sure that the total adds to 100%.
    a)  Labs which charge on average over $250 or more per unit %
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    b)  Labs which charge on average between $176-$250 per unit %
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    c)  Labs which charge on average between $101-$175 per unit %
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    d)  Labs which charge on average less than $100 per unit %
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Value Added Programs

13. Divine Dental Studios also offers some programs that provide value to our clients in conjunction with the work that we perform. Please indicate whether you are interested in receiving information about the following programs. Yes or No?:
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14. I/We affirm that the foregoing information contained in this application is presented for purposes of establishing credit and is true, complete, and correct. Divine Dental Studios is authorized to make any investigation of my credit or employment status whether directly or through any agency employed by Divine Dental Studio for that purpose. You may also disclose to any interested parties or agencies your experiences with this account. I/We agree to inform Divine Dental Studios immediately of any matter that will cause significant change in my financial condition on existing or new orders. I understand that Divine Dental Studio will retain this credit application whether or not it is approved. If this application is accepted by Divine Dental Studios, I/We agree to the following terms:
    a)  Please provide below the credit card which you want to use to guarantee payment of all charges:
    Credit Card Type
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    b)  Any invoice, which is not paid when due, will accrue interest of one and one half percent (1.5%) per month on the unpaid balance from the invoice until payment in full is received.
    c)  In the event the account becomes delinquent after 45 days, Divine Dental Studios is authorized to satisfy the outstanding balance by credit card which will be provided by applicant below, until such time that a notice is received by Divine Dental Studios canceling the authorization.
    d)  In the event the company is a corporation, I understand and agree that by signing below I personally guarantee payment of any and all monies owed.
    e)  In the event that it becomes necessary to file an action to recover any amounts due under this agreement, I understand and accept that the court shall award prevailing party in such actions all costs, including reasonable attorney’s fees.
    f)  This agreement shall be governed by and consulted and enforced under the laws and judicial decisions of the State of California. Any and all actions to enforce this Agreement shall be commenced in the County of Los Angeles.
    g)  This agreement shall act as a revolving Agreement and shall apply to any and all future orders placed with Divine Dental Studios by applicant.
    h)  This agreement shall be binding on and shall insure to the benefit of heirs, executors, administrators, successors, or assigns of respective parties.