MDA Television Network Member
Please fill out the order form below to schedule your Private Television Channel on the MDA Television Network. All fields below are required & noted with an asterisk (*). Click on the Submit button to send the form. Thank you!
MDA PTC 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)
Please select your dental practice type.
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 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
DTV Mailing list
Side Bar Catalog
State Dental Associations
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