Gould Oral and Maxillofacial Radiology - Referring Office Registration

Account Registration

Referring Dental Office Details

Dental Office Name*

Dental Office Email Address*

for all portal notifications

Dental Office Phone Number*

Dental Office Address*

Primary Contact Person

CBCT Unit Manufacturer & Model

Referring Dentist Details

Dentist First Name*

Dentist Last Name*

Specialty

Electronic Signature Agreement

Please review and agree to the Practice Terms and Conditions before signing

Electronic Signature Agreement

By signing electronically, I represent that I have the authority to bind the health/dental care practice ("Practice") requesting services, that I have read and understand the Gould Oral and Maxillofacial Radiology (GOMR) Terms and Conditions, and that I accept and agree to be bound by the terms and conditions set forth in the Agreement on behalf of the Practice as of the date of this electronic signature.