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
This is a required field. Please enter your first & last name. Thank you.
This is a required field. Please enter the full name of the dental practice. Thank you.
Solo or Partner
Group (3 or more Dentists)
Please select your dental practice type.
Group Practice Dentists' Names
If you have a Group Practice with 3 or more dentists, please enter the first and last names of the other Group Practice members.
This is a required field. Please enter the email address of your dental practice. Thank you.
This is a required field. Please enter the telephone number of your dental practice. Thank you.
This is an optional field. Please enter the mobile number you would like as an alternate contact. Thank you.
This is a required field. Please enter the business address of your dental practice. Thank you.
How did you hear about us?
MDA Journal Ad
MDA Journal Article
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)
Choose one or more options.
Let us know how we can help you.
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Side Bar Catalog
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