First Name
Last Name
Company Name
Email
Practice Phone
PMS
PMS System*
Dentrix Enterprise
Eaglesoft
Fuse
Denticon
MacPractice
Dentrix
Open Dental
PracticeWorks
SoftDent
Curve
XLDent
Other
State
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Number of Locations
1 to 4
5 to 15
16 to 50
51 to 150+
Role
CEO/President/Founder
Doctor
IT
Marketing
Office Manager
Operations
Other
Role
Doctor
Front Office
Office Manager
Other
Comments