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* 1. Contact Name:

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* 2. Contact Title

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* 3. Contact Phone Number:

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* 4. Contact Email Address:

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* 5. DSO Legal Name and/or DBA:

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* 6. Website:

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* 7. Motion Calculator - Average Appointment Interval in Weeks for Full Braces Treatment? 4, 6, 8, 10, 12, Other _______?

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* 8. Motion Calculator - Average Treatment Time in Months for Full Braces Treatment? 18, 22, 24, 26, 30, Other _______?

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* 9. Motion Calculator - Average Treatment Fee for Full Comprehensive Braces Treatment?

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* 10. Motion Calculator - Total Number of Orthodontic Consults in Prior Year?

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* 11. Motion Calculator - Total Number of Orthodontic Starts (Bondings) in Prior Year?

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* 12. Aligner Calculator - Do you offer discount for PIF patients for Aligners?

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