Q: Office Email
A: OFFICE EMAIL

Q: Practice Name
A: PRACTICE NAME

Q: Address
A: OFFICE STREET

Q: City
A: CITY

Q: State
A: STATE

Q: Zip Code
A: ZIPCODE

Q: Office Phone
A: OFFICE PHONE

Q: First Name
A: DENTIST FIRST NAME

Q: Last Name
A: DENTIST LAST NAME

Q: Degree
A: DDS

Q: Area of Practice
A: General Dentist

Q: Experience
A: 20+ years

Q: Languages Spoken
A: English

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: Yes

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: Yes

Q: Have your hospital privileges, if any, ever been revoked, suspended, reduced, or not renewed; have disciplinary proceedings ever been instituted against you; or are any of these actions now pending with respect to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: Yes

Q: Have you ever voluntarily relinquished hospital privileges, DEA Registration, academic appointments or any other professional status while an investigation was conducted?
A: Yes

Q: Have any complaints been filed against you with a dental/professional society?
A: Yes

Q: Have any professional liability judgments been entered against you, including arbitration awards or are there professional liability suits currently pending against you?
A: Yes

Q: Have any professional claim settlements, not involving litigation or arbitration, been paid by you or paid on your behalf?
A: Yes

Q: Has your professional liability insurance ever been canceled or has professional liability insurance ever been denied?
A: Yes

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: Yes

Q: Do you now have or have you had a chemical dependency/substance abuse problem?
A: Yes

Q: If you answered "Yes" to any of the questions above, please provide a detailed explanation, including the outcome.
A: YES AGREEANCE TEXT

Q: Malpractice Document
A: View Document

Q: State Dental License
A: View Document

Q: ELECTRONIC SIGNATURE & AGREEMENT
A: I confirm that I am the provider completing this form., I certify that all information I have provided is true, accurate, and complete to the best of my knowledge., I confirm that all uploaded documents are current, valid, and accurately represent my professional credentials., I understand that MatchMyDentist may verify any information or document submitted and that submission does not guarantee approval or participation., I have read and agree to the MatchMyDentist Provider Terms & Conditions and agree to be legally bound by them, including provisions related to fees, independent contractor status, dispute resolution, and indemnification., I consent to receive communications and to enter into this agreement electronically.

Q: Full Legal Name (Electronic Signature)
A: FULL LEGAL NAME

Q: Final Step
A: Yes