Original Questionnaire Responses
Q: Office Email
A: Ttdast
Q: Practice Name
A: rtewt
Q: Address
A: ertret
Q: City
A: retret
Q: State
A: tyreyhdsfy
Q: Zip Code
A: 32872
Q: Office Phone
A: yesrtyerty
Q: Degree
A: DDS
Q: Area of Practice
A: General Dentist
Q: First Name
A: year
Q: Last Name
A: jfdg
Q: Experience
A: 0-5 years
Q: Languages Spoken
A: English
Q: How many new patients are you looking for monthly?
A: 6-15 new patients
Q: Ready to Start Receiving Matches?
A: Yes, I want to start as soon as my profile is approved
Q: URL
A: https://google.com
Q: Has your license to practice in this state or any other state been denied, restricted, limited, suspended or revoked; have you ever been reprimanded by a state licensing agency; or are any of these actions pending with respect to your license?
A: No
Q: Has your DEA Registration ever been restricted, limited, suspended or revoked, or are any of these actions pending with respect to your DEA Registration?
A: No
Q: Have your hospital privileges, if any, ever been revoked, suspended, reduced, or not renewed; have disciplinary proceedings ever been instituted against you; or are any of these actions now pending with respect to your hospital privileges?
A: No
Q: Have you ever voluntarily relinquished hospital privileges, DEA Registration, academic appointments or any other professional status while an investigation was conducted?
A: No
Q: Have any complaints been filed against you with a dental/professional society?
A: No
Q: Have any professional liability judgments been entered against you, including arbitration awards or are there professional liability suits currently pending against you?
A: No
Q: Have any professional claim settlements, not involving litigation or arbitration, been paid by you or paid on your behalf?
A: No
Q: Has your professional liability insurance ever been canceled or has professional liability insurance ever been denied? ®Yes ®No
A: No
Q: Have you ever been convicted of a felony or do you have any felony or misdemeanor charges pending (other than minor traffic offenses)?
A: No
Q: Do you now have or have you had a chemical dependency/substance abuse problem?
A: No
Q: If you answered "Yes" to any of the questions above, please provide a detailed explanation, including the outcome. If you prefer to submit supporting documentation, you may email it to credentials@matchmydentist.com.
A: yte
Q: Only the doctor may complete and certify this form. Are you the doctor personally completing this form?
A: Yes
Q: Please type your full legal name as your electronic signature.
A: tsat
Q: By clicking "I accept" below, you agree to the above certification terms and conditions and consent to electronic signature
A: Yes