Daly Oral & Maxillofacial Radiology Inc.

Dental Office Name*

Dental Office Email Address*

for all portal notifications

Dental Office Phone Number*

Dental Office Address*

Primary Contact Person

CBCT Unit Manufacturer & Model

Dentist First Name*

Dentist Last Name*

Specialty*

Please specify*

Are there other dentists in this practice?*

No

Yes

Dentist First Name*

Dentist Last Name*

Specialty*

Please specify*

Are there other dentists in this practice?*

No

Yes

Dentist First Name*

Dentist Last Name*

Specialty*

Please specify*

Are there other dentists in this practice?*

No

Yes

Dentist First Name*

Dentist Last Name*

Specialty*

Please specify*

Electronic Signature Agreement

Please review and agree to the Practice Terms and Conditions before signing

Electronic Signature Agreement

By signing electronically, I represent that I have the authority to bind the health/dental care practice ("Practice") requesting services, that I have read and understand the Daly Oral and Maxillofacial Radiology Inc. ("Daly OMR Inc.") Practice Terms and Conditions ("Agreement"), and that I accept and agree to be bound by the terms and conditions set forth in the Agreement on behalf of the Practice as of the date of this electronic signature.

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Dental Office Details

Referring Dentist Details

Electronic Signature Agreement