Client Profile - Dentalle

Ready to set up your Dentalle account? Just fill out the following information completely. If you require assistance, email support@dentalle.com or phone us at (561) 391-9437. Once we receive your completed profile, we will reach out within 1 business day to get you started!

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Business Name

Business Phone #

Main Contact Person

First

Last

Main Contact Email

Business Address

Second Contact Person

First

Last

Second Contact Email

Emergency/Weekend Phone #

Our office plans to send lab cases

Digitally
Physically
Both

PAYMENT INFORMATION

Expiration Date

Security Code

Billing Address (only fill out if different that business address)

Signature

1. I am authorized to represent the organization listed above. 2. I authorize Dentalle Inc. to charge the above credit card for all orders and any additional fees associated with such orders. 3. In the event that the organization listed above has an outstanding overdue invoice due to nonpayment exceeding Dentalle's terms, I authorize Dentalle to charge the above credit card or any other valid credit card on file. 4. I understand that the organization above is responsible for all costs incurred by Dentalle to collect including but not limited to collection, attorney, and legal.