MDA PTC Preorder Form

MDA Television Network Member

Please fill out the pre-order form below to reserve a WiFi kit for your fully managed, custom, MDA Private Television Channel for your Dental Practice.

All fields below are required & noted with an asterisk (*). Click on the Submit button to send the form. Thank you!

Free MDA Dental TV Channel Order Form

* Indicates required field

Name *

First

Last

Practice Name *

Practice Type *

Solo or Partner Group (3 or more Dentists)

Group Practice Dentists' Names *

Email *

Office Phone *

Mobile Phone *

Address *

Line 1

Line 2

City

State

Zip Code

Country

How did you hear about us? *

How many TVs do you have in your Dental Practice? *

What are you interested in? *

WiFi installation kit for the MDA TV Channel Info about Fully Managed MDA Private TV Channels Other (described in the Comments)

Comments *

I agree to receiving marketing and promotional materials

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