DSO Organizations - siosdental

DSO Organization REGISTRATION

DSO NAME: *

ADMINISTRATOR NAME: *

BASE LOCATION: *

CONTACT PERSON: *

CONTACT CELL #: *

CONTACT EMAIL: *

Yes, I want to register & become SiOS™ Certified in multiple locations

Yes, I want to take advantage of the Pre Order Lab Special Promotion (Chicago LMT 2025)

Yes, I approve my credit card deposit of $500.00 per location (Fully Refundable End of 2025*)

Name of your SiOS rep: *

# of locations: *

# of Doctor/Lab personnel to be trained: *

Today’s Date *

AMEX

MasterCard

VISA

Discover

Name on card: *

Address of card: *

Your signature *

Enter card number *

MM/YY *

CVC/CVV *

card holder name *

The package price of the DSO kit: $Custom based on # of locations & personnel

(Pre Order VIP Special: $TBD thru Feb 28,2025)

You are authorized by company to engage in this transaction on behalf of your company.

The pricing for DSO type organizations will vary based on numerous factors. Group pricing will be determined by the SiOS admin staff based on # of factors.

By submitting this form and a single deposit (fully refundable), you are committing to scheduling a specific Zoom meeting with the SiOS staff to help determine your specific needs and goals. Final pricing will be determined after that meeting.

The SiOS™ package deposit is fully refundable. Expected commencement of delivery/install will be Q3/4 of 2025. Educational training course dates are being set up in specific locations throughout the U.S. Any refund request must be submitted in writing by email *within the specified 90-day period since submission to: Before the end of 2025 or manufacturer install date is confirmed.