ShopADoc® | Dentist Registration

Dentist Registration

NameFirst

Last

Designation

Personal Email

Password

Passwords are case sensitive and must be at least 8 characters with 1 uppercase, 1 lowercase, and 1 numeric or special character.

Licensed Dentist's address on file with the State Board of Dentistry

Street

Suite #

City

State

Zip Code

Office address where services are rendered
Each office requires a separate registration.

Office Email

Office

State Dental License #

Under penalty of law, I certify I hold an active unrestricted license to practice dentistry within the state of and at the address of the dental office listed above. I am without pending investigation for disciplinary/ administrative action(s) against me. Should my status change, I agree to notify ShopADoc The Dentist Marketplace Inc. immediately by email to admin@shopadoc.com and to refrain from further participation on this site until reinstatement to good standing by the State Board of Dentistry. I accept the User Agreement, Privacy Policy, House Rules, and FAQ.

I authorize the below amount be charged to the card listed below for payment of the Annual Registration Fee to access the ShopADoc® Auction Site. The Annual Registration Fee payment will be a revolving charge to this card on my anniversary date of registration. I permit ShopADoc® to provide my office contact information to the Client following a successful auction pairing for appointment scheduling. Payments, once made, are not refundable.

Electronic SignaturePlease sign by typing your full legal First, MI, & Last Name as registered dentist.

Card Number

Security Code

Expiration

Card Zip Code

Total Amount Due $99.99

Name on Card

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Dentist Registration

Licensed Dentist's address on file with the State Board of Dentistry

Office address where services are rendered Each office requires a separate registration.

Office address where services are rendered
Each office requires a separate registration.