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TDA Perks Television Network Member

Please fill out the order form below to opt-in for your Private TV Channel on the TDA Perks Television Network. All fields below are required & noted with an asterisk (*). The cost for the first year is $355.50, which is a 25% savings over the regular price or the equivalent of 3 months free. You will be billed full price at your annual renewal. Thank you.

    TDA-TX PTC Opt-in Form

    This is a required field. Please enter the first & last name of the dentist. Thank you.
    This is a require field. Please enter the full name of the dental practice. Thank you.
    This is a required field. Please select your dental practice type. Thank you.
    If you have a Group Practice with 3 or more dentists, please enter the first & last names of the other Group Practice members. Thank you.
    This is a required field. Please enter the email address of the dental practice. Thank you.
    This is a required field. Please enter the telephone number of the 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 the dental practice. Thank you.
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