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New Customer Questionnaire

  • This short questionaire will help us better determine what your needs are. All information supplied is confidential. It will take about 10 minutes to complete this form. Once you submit it we will contact you within a few minutes to discuss your specific needs.

  • Contact Information

  • Our I.T. strategy isn't working for us, and we need some new ideas.We need a few minor problems fixed.Preparing for a remodel or new construction projectNeed a price quote for our next generation computer systems.Interested in intraoral cameras.Interested in patient education software.Interested in becoming paperless with Dentforms.

    • Software Systems

    • DentrixEaglesoftSoftdentPracticeworksOther
    • EaglesoftDentrix Image 4.x or higherDexisSchick CDRSidexis 5.x or higherVixwinTigerviewKodakApteryxOther / I don't know!

      • Hardware Systems

      • YesNoI don't know
      • YesNo
      • None1-5 computers6-10 computersMore than 11 computers
      • 1-2 years3-4 years5 years
      • 1-2 years3-4 years5 years
      • 1-2 years3-4 years5 years

      • Service History

        • The Joseph CompanyProgressive SolutionsMiken TechnologiesPatterson DentalOther

        • Our Call to Action

        • We want to meet with you to study your systems and answer your questions in person. Please provide 3 dates in order of preference that would work for you.

        • (mm/dd/yyyy)
        • (mm/dd/yyyy)
        • (mm/dd/yyyy)

        • If you would prefer a different action, such as a call back at a specific time, date, and/or telephone number, please include that information below.

        • When you send this form, you will be contacted within a few minutes to review the data and schedule a time for your site survey based on your date choices.

        • Referral Information

        • Referral from a colleagueReferral from an industry professionalInternet search