NOTIFY ME WHEN THE LEGAL LOOK IS AVAILABLE

*required

Practice Information:

PRACTICE NAME*

NAME OF PRIMARY DENTIST*

NAME OF EMPLOYEE RESPONSIBLE FOR YOUR CUSTOM PROGRAM*

EMAIL OF EMPLOYEE RESPONSIBLE FOR YOUR CUSTOM PROGRAM*

COOPERATIVE ACCOUNT# (Found on Invoice. Optional)

DO YOU ALREADY HAVE A MYHAPPYMOUTH PROGRAM SET UP?*

—Please choose an option—NoYesI'm currently in the process of setting one up.

We will keep you in the loop and let you know when this is available.