Welcome To ELITE Dental Alliance!

Unique ID

Practice Information

Let's start off with a few simple details about your practice.

Practice Name(Required)

Specialty(Required)

Practice Website Address

Practice Phone Number(Required)

Gross Production Level(Required)

Year Founded

Practitioner Information

Tell us about practitioners in your practice.

Practitioner First Name(Required)

Practitioner Last Name(Required)

Primary Practitioner Email(Required)

(This will be used to create your ELITE Membership Username)

Enter Email Confirm Email

Primary Practitioner Phone(Required)

Primary Practitioner License Number(Required)

Number of Practitioners(Required)

Practitioner 2

Name

Practitioner 2 #

License Number

Practitioner 3

Name

Practitioner 3 #

License Number

Practitioner 4

Name

Practitioner 4 #

License Number

Practitioner 5

Name

Practitioner 5 #

License Number

Practitioner 6

Name

Practitioner 6 #

License Number

Practitioner 7

Name

Practitioner 7 #

License Number

Practitioner 8

Name

Practitioner 8 #

License Number

Practitioner 9

Name

Practitioner 9 #

License Number

Practitioner 10

Name

Practitioner 10 #

License Number

Location Information

Please include the details for all of your locations below.

Primary Location Address(Required)

Street Address Address Line 2 City State ZIP Code

Primary Location Phone(Required)

Primary Location Tax ID Number (EIN)(Required)

How many locations do you have?(Required)

If locations exceed 10, please contact support@elitedentalalliance.com to add additional locations.

Location #2

Location #2 Practice Name

Location #2 Address(Required)

Street Address Address Line 2 City State ZIP Code

Location #2 Phone(Required)

Location #2 Tax ID Number (EIN)

Location #3

Location #3 Practice Name

Location #3 Address(Required)

Street Address Address Line 2 City State ZIP Code

Location #3 Phone(Required)

Location #3 Tax ID Number (EIN)

Location #4

Location #4 Practice Name

Location #4 Address(Required)

Street Address Address Line 2 City State ZIP Code

Location #4 Phone(Required)

Location #4 Tax ID Number (EIN)

Location #5

Location #5 Practice Name

Location #5 Address(Required)

Street Address Address Line 2 City State ZIP Code

Location #5 Phone(Required)

Location #5 Tax ID Number (EIN)

Location #6

Location #6 Practice Name

Location #6 Address(Required)

Street Address Address Line 2 City State ZIP Code

Location #6 Phone(Required)

Location #6 Tax ID Number (EIN)

Location #7

Location #7 Practice Name

Location #7

Street Address Address Line 2 City State ZIP Code

Location #7 Phone(Required)

Location #7 Tax ID Number (EIN)

Location #8

Location #8 Practice Name

Location #8

Street Address Address Line 2 City State ZIP Code

Location #8 Phone(Required)

Location #8 Tax ID Number (EIN)

Location #9

Location #9 Practice Name

Location #9

Street Address Address Line 2 City State ZIP Code

Location #9 Phone(Required)

Location #9 Tax ID Number (EIN)

Location #10

Location #10 Practice Name

Location #10

Street Address Address Line 2 City State ZIP Code

Location #10 Phone(Required)

Location #10 Tax ID Number (EIN)

Referrals

We'd love to hear more about how you found out about ELITE Dental Alliance.

How did you hear about ELITE?

Other

Who may we thank for the referral?

Type Referrer Name

Which ELITE Member Advocate assisted you?

Payment

Make your annual fee payment below.

Full Access to ELITE vendor platform.

- Exclusive deals from 100+ vendors
- Avg annual savings of ~$25k
- Benco Select Membership ($1299 value)
- AO Edge Membership ($125 value)
- Staples Bus. Advantage ($299 value)
- Up to 5 locations & unlimited user accounts

ELITE Membership

Price:

Credit Card(Required)

American Express

Discover

MasterCard

Visa

Card Number

Expiration Date

Security Code Cardholder Name

Promo Code

Coupon Price

Total

Billing Address(Required)

Street Address Address Line 2 City State ZIP Code

Account Confirmation(Required)

Did you use the same email in the payment form above that you did for the Main Contact in Step 3?

Yes

No

Email

This field is for validation purposes and should be left unchanged.

Password(Required)

Enter Password Confirm Password

Strength indicator

Member Agreement Statement:(Required)

By checking this box, you are agreeing to ELITE’s membership agreement and have given consent for future communication about relevant services and products on the platform.

Agree

Expires In

New Member Registration Form

Practice Information

Practitioner Information

Main Point of Contact

Location Information

Location #2

Location #3

Location #4

Location #5

Location #6

Location #7

Location #8

Location #9

Location #10

Referrals

Payment

Full Access to ELITE vendor platform.

Expires In

New Member Registration Form

Practice Information

Practitioner Information

Main Point of Contact

Location Information

Location #2

Location #3

Location #4

Location #5

Location #6

Location #7

Location #8

Location #9

Location #10

Referrals

Payment

Full Access to ELITE vendor platform.

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