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Background Information
In your specialty are you?
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Neither
Length of years in practice
Any disciplinary actions against you or your practice within the last 10 years?
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Yes
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Yes
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Please list any additional education &/or certification information you would like to include:
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By clicking below and submitting this application, I certify that all the information above is true to the best of my knowledge and held to be true. I also understand and agree that NY Top Docs (a division of USA Top Docs) may in their sole discretion, to approve or deny my application with or without cause. I understand and agree that NY Top Docs will conduct a background check (free of charge to myself) to review my license, malpractice, education, training, and employment. I also acknowledge that by providing my fax number and/or email addresses on this form I am giving USA Top Docs, permission to use this information in perpetuity and from time to time send marketing related information via fax and/or email. I also acknowledge an ongoing business relationship with USA Top Docs. I understand that my information will never be sold or distributed to anyone outside of USA Top Docs. If I wish to be removed from USA Top Docs (or its subsidiaries) communication, I must submit the request in writing to
[email protected]
, via fax to 908-288-7241 or via phone message by calling 908-288-7240 x 100 24/7/365. For this request to be valid (i) the request must clearly identify the fax number(s) to which this request relates too and (ii) the request must be communicated by one of the methods listed above.
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By Checking This Box, I Am Signing This Application
Date
Month
Day
Year
Name
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Name
This field is for validation purposes and should be left unchanged.
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Step
1
of
3
33%
Contact Information (Required)
Practice Name
*
Dentist's Name
*
First
Last
Address
*
Street Address
Address Line 2
City
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
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Maryland
Massachusetts
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Northern Mariana Islands
Ohio
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Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
Office Phone
*
Ext
Office Fax
*
Dentist Email
*
Office Email
Website
Specialty/Specialties
*
Background Information
In your specialty are you?
Board Certified
Board Eligible
Neither
Length of years in practice
Any disciplinary actions against you or your practice within the last 10 years?
Yes
No
Up to date on all malpractice insurance?
Yes
No
Any malpractice claims within the last 10 years?
Yes
No
Dental School
Year of commencement
Residency Institution
Year of commencement
Please list any additional education &/or certification information you would like to include:
Affirmation (Required)
By clicking below and submitting this application, I certify that all the information above is true to the best of my knowledge and held to be true. I also understand and agree that NY Top Docs (a division of USA Top Docs) may in their sole discretion, to approve or deny my application with or without cause. I understand and agree that NY Top Docs will conduct a background check (free of charge to myself) to review my license, malpractice, education, training, and employment. I also acknowledge that by providing my fax number and/or email addresses on this form I am giving USA Top Docs, permission to use this information in perpetuity and from time to time send marketing related information via fax and/or email. I also acknowledge an ongoing business relationship with USA Top Docs. I understand that my information will never be sold or distributed to anyone outside of USA Top Docs. If I wish to be removed from USA Top Docs (or its subsidiaries) communication, I must submit the request in writing to
[email protected]
, via fax to 908-288-7241 or via phone message by calling 908-288-7240 x 100 24/7/365. For this request to be valid (i) the request must clearly identify the fax number(s) to which this request relates too and (ii) the request must be communicated by one of the methods listed above.
Signed
*
Electronic Signature
By Checking This Box, I Am Signing This Application
Date
Month
Day
Year
Name
*
First
Last
Email
This field is for validation purposes and should be left unchanged.
Δ