Home
About
Advertisers
Membership
Press
Contact Us
AzDA Perks PTC Members Order Form
Please fill out the order form below to order your Private Channel (PTC) on the AzDA Perks Television Network. All fields below are required & noted with an asterisk (*). Click on the Submit button to send the form. Thank you.
AzDA PTC Order Form
*
Indicates required field
Name
*
First
Last
This is a required field. Please enter your first & last name. Thank you.
Practice Name
*
This is a required field. Please enter the full name of the dental practice. Thank you.
Practice Type
*
Solo or Partner
Group (3 or more)
This is a required field. Please select your dental practice type. If you are a Group practice, please enter the first & last names of the other members. Thank you.
Group Practice Dentist's Name
*
If you have a Group Practice with 3 or more dentists, please enter the first and last names of the other members.
Email
*
This is a required field. Please enter the email address of the dental practice. Thank you.
Office Phone
*
This is a required field. Please enter the telephone number of dental practice. Thank you.
Mobile
*
This is an optional field. Please enter the mobile phone you would like as an alternate contact number. Thank you.
Address
*
Line 1
Line 2
City
State
Zip Code
Country
This is a required field. Please enter the business address of the dental practice. Thank you.
How did you hear about us?
*
Direct Mail
Email
Inscriptions Journal Ad
Inscriptions Journal Article
Member Referral
Tradeshow
This is a required field. Please select from the drop down menu. Thank you.
Submit
Home
About
Advertisers
Membership
Press
Contact Us