Account

Activation

Practice + Location Details

Here we go! Help us put this location into the context of your business and practice at large, by completing the requested details below. Be sure to click the ℹ️ above a field if you have questions!

PRACTICE INFO

Business Name *

Office Location Name *

# of Total Locations *

Website (best) *

Email (business) *

Phone (direct/primary) *

Enter a 9 digit phone number

Phone (alternative) *

Enter a 9 digit phone number

Phone (preferred/mobile) *

Enter a 9 digit phone number

LOCATION DETAILS

# of Doctors *

# of Hygenists *

Speciality Services? (Select all that apply) Please select atleast one option

Ortho

Oral Surgery

Implant

Cosmetic

Endo

Prostho

Perio

Other

SHIPPING ADDRESS

Business Name *

Location Name *

Attn *

Recipient's name or job title

Address (street = suite) *

City *

Zip Code *

Business Name *

Location Name *

Attn *

Recipient's name or job title

Address (street = suite) *

City *

Zip Code *

ORDERING INSIGHTS (~/ MONTHLY)

Average Monthly Office Revenue

50k

50k
100k
150k
200k
250k

Average Monthly # Of Orders

1 order
5 orders
10+ orders

Average Monthly Supply Spend

$1,000
$5,000
$10,000
$15,000

Practitioner Licenses + Credentials

Practitioner Name *

DEA License Number

DEA License Expiration Date

(MM/DD/YYYY)

National Provider ID (NPI) *

EIN Number *

State License Number *

State License Expiration Date *

(MM/DD/YYYY)

Next Step!

Our team will begin the onboarding process once we’ve received your intake worksheet with the necessary information captured. Through this process we’ll be building your customized Wellplaece portal where you’ll be ordering. In addition to setting up your account dashboard, we’ll be analyzing your ordering history and have a final SKU catalog for your substitution approval required. Without explicitly indicated substitution preferences, we’ll leverage our supplier database to match at a product specification level. We expect to have all of this completed quickly and will communicate with you throughout our receiving of your intake information through your onboarding and order placement.

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