Onboarding Form

Welcome to DentalEMR!

We thank you for trusting us as your Endodontic Partner in Success!
Once you have completed this form, our team will create your practice database, send you and your team invites to login and initiate your practice setup for you. If you have any questions, please direct them to your assigned Practice Success Manager.

Full name of practice:

Administrative Setup

Practice Primary Location Address

Street Address:

Street Address Line 2:

City:

State / Province:

Postal / Zipcode:

Practice Phone Number:

Practice Fax Number:

Admin Email Address:

Practice Web Address:

# of Locations:

Please provide for each location, the Location Name, Address, Phone and Fax:

Operating Hours (if more than one location, please specify)

Please list all current non-provider staff, their roles and their unique email address which will be used as their username to login to DentalEMR.

If you are migrating from a previous software, please specify the name of the software:

Do you have 2 tablets ready to use for electronic workflows?

Intra-oral X-Ray sensor Brand/Model(s) you will be using:

# of X-Ray Sensors:

# of Operatory Rooms:

CBCT Brand / Model:

Best Administrative Point of Contact for your Practice

First Name:

Last Name:

Their Role:

Their Email:

Their Phone:

Notice of Privacy Practices URL on your website. If you do not already have a privacy policy and need a sample to create your own, we are happy to provide one.:

Google Business Profile Review URL:

ePrescriber Setup

Doctor 1

First Name:

Last Name:

Date of Birth:

DEA #:

License #:

License State:

Add. License #:

Add. License State:

Tax ID:

NPI:

Email:

Phone Number:

Full-time or Part-time:

Practice Logo (JPEG/PNG)

We will assist you with digitally setting up your consent forms for electronic signatures. If you already have consent forms ready to use, please upload them here. If you do not have any consent forms and need samples to create your own, we are happy to provide them.

HIPAA Notice (PDF)

You are required to provide a copy to patients in your new patient paperwork, it is recommended that your website designer place a page specifically denoted to HIPAA Privacy Policy on your website for patient ease of access. We will use this link as a reference in our electronic new patient paperwork.

Clinical Consent Forms (PDF)

This will be used for collecting patient reviews.

End of Year Promo — Click to Save $1500+

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Welcome to DentalEMR!

End of Year Promo — Click to Save $1500+

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Welcome to DentalEMR!

Your Endodontic software search ends here!

Take your 30-sec quiz to learn if DentalEMR is the best fit for you.