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March 14, 2010  
REGISTRATION: Dental Professional Locator

Please fill out the form below to become a registered professional on Dental1.org. When approved you will receive the following member benefits:

  • Practice information listed in the Dental Professional Locator
    		•   
  • Member-exclusive opportunities

    • The Dental1.org Dental Professional Locator will allow patients interested in dental implant and tissue regeneration therapy to contact you directly. Please complete the form below and click "OK" to submit when your information reads exactly as you would like it to. The required fields are indicated with an asterisk (*). Approval can take 1-2 business days.

    Note: Your personal information will not be sold or shared with any parties outside of Dental1.org. Please read our privacy policy for further information.

     Name * First:
    Last:
     Title *
     Specialty *    
     E-mail *
     
    Display e-mail within the Locator section
     
    I am interested in adding patient testimonials / before and after pictures to my listing.
    If you would like to attach a photo, e-mail a jpg or gif file to editor@body1.com. Be sure to include your name in the e-mail.
     Languages  Spoken   Payment Plans  Accepted 
     Biography 
     (250 words)
    (Maximum words: 250)
    You have words left.         		 Personal  Message 
     (250 words)
    (Maximum words: 250)
    You have words left.
    What to Bring to Your Appointment 
     (250 words)
    (Maximum words: 250)
    You have words left.         		Use the left-hand box to give patients a message on what to expect or what to bring to their appointment.
    Practice Location
     Address 1 *
     Address 2 
     City *
     State *
     Zip *
     Country *
     Work Phone * 
     Fax Number 
     Web Site 
    Secondary Practice Location
     Address 1 
     Address 2 
     City 
     State 
     Zip 
     Country 
     Work Phone 
     Fax Number 
     Web Site 
      Account Information: You will use this information to sign in and modify your locator listing.  
     
     
     Username *
       Password: For security purposes your initial password will be e-mailed to the address you provide
    Lost Password Question Password Answer *
       Example:
       Lost Password Question: What is my dog's name?     >>>>>    Password Answer: Spot
       If you forget your password we'll ask you the answer to your password question.
       Please select your desired e-mail format.
    		     
    		 
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