Clinic/Practice Name


Address


City


State


Zip Code


Phone #


Fax #


Practice Administrator* (First and Last)

Practice Administrator Email


ADSO Member or 75+ Providers?
No Yes

list all non-providers (proxy clinicians) who will access DoseSpot and their email addresses (required if using stand-alone)

*Designate a staff member (typically an office manager) who will be the point of contact and own the DoseSpot sign up process for providers and proxy clinicians. This person will need admin permissions in Open Dental and must be a non-provider. To register additional proxy (non-provider) users please send an email with their first and last names to erx@opendental.com.

We are not currently using Open Dental. I acknowledge that by signing up for the stand-alone version of DoseSpot the information will not be integrated with my Open Dental. Once we sign up with Open Dental, this information will not transfer into my Open Dental database.