Practice Owner

Registration

"*" indicates required fields

Practice Owner's Information

First name*

Last Name*

Title (DDS, DMD)

Email*

Mobile Phone*

Gender

Practice Information

Practice Name*

Practice Street Address*

City*

State*

Zip Code*

Practice Phone

Practice Website

Matching Information

What Specialties Are You Interested In Matching With?*

Endodontics

GP Associate

Oral Surgery

Orthodontics

Pedodontics

Periodontics

Restorative Prosthodontist

Surgical Prosthodontics

How Did You Hear About Us?

Consent*

By registering as a Practice member of Pair Dental, Inc. (“Pair”), I understand that Pair will attempt to find suitable treating providers to match with my practice. I agree that any providers introduced by Pair are confidential and, before I work with a matched provider, I will need to sign additional agreements with Pair & the treating provider. I agree that I will not circumvent Pair and will not work directly with a matched specialist without signing the additional agreements. I understand and agree that any circumvention can lead to a lawsuit in the Superior Courts of Los Angeles County.

I Accept

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