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1.855.YES.LABS (937-5227)

Office Forms

Credit Card on File Policy

New Office Form

* Required

Account RegistrationRequired for online account and case tracking.

Email *

Password *

Confirm Password *

General Information

Office/Practice Name *

Street Address *

City

State/Province

ZIP / Postal Code

Phone *

Which type of impressions do you typically use? *Digital ScansPhysical Impressions

If you have a scanner, please indicate brand

Days OpenSunMonTuesWedThursFriSat

Working Hours

Contacts

Office Manager

Phone/Email

Billing Contact

Phone/Email

Dr. Assistant (for lab questions)

Phone/Email

Doctor Preferences (optional)

Doctor's Name

Upload Doctor's Signature

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ContactsNormalLightHeavy

OcclusionNormalLightOut of Occlusion

If insufficient occlusal clearanceCall DoctorReduce PrepReduction CopingRelieve OpposingMetal OcclusalOther (please specify)

Other

Payment InformationTo streamline the billing process, we require all offices to keep a credit card on file.

Cardholder Name *

Card Type *MastercardVisaAmerican ExpressDiscoverOther

Card Number *

CVC *

Exp Month *

Exp Year *

Billing Address

Billing ZIP *

Consent *

I confirm that the information provided is accurate, and I agree to the billing and case processing policies of Ultra Core Labs. I authorize Ultra Core Labs to store my payment method on file for seamless transactions.

Payment Update Form

Office Name *

Phone Number

Cardholder Name *

Card Type *

Card Number *

Month *

Year *

CCV *

Billing Address

ZIP *

Consent *

I confirm that the information provided is accurate, and I agree to the billing and case processing policies of Ultra Core Dental Laboratories. I authorize Ultra Core Labs to store my payment method on file for seamless transactions.

info@heralabgroup.com
1.855.YES.LABS
(1.855.937.5227)

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