Office Profile

To better understand your current business practices and office configuration, we ask that you take a few
minutes to fill out the following form, completely and accurately. Leave no blank fields; use N/A, where
applicable. For order processing, this form must be attached to all new DPMS orders.

TARGET Go LIVE Request Date:

(please consider lead time required for data services work)

Primary Contact (Name, Phone, Email):

HW Tech (Name, Phone, Email):

Current DPMS & version:

Imaging SW & version:

FMX sensors, Pan/Ceph, CBCT:

# of Locations (shared or separate databases)

Current Integrated Services with vendor names (eClaims, Statements, ePresciptions, ePayments,

Reminders, Recalls):

Email application, integrated?

Practice Owner:

# of Dentist/Doctors:

Multispecialty? (Ortho,Perio,Endo,OMS)

Is your office currently using digital clinical charting? YES NO Some Locations

Do you submit Medical Insurance claims? YES NO

Conversion limitations discussed during sales process? YES NO

NOTE:
If coming from Dentrix G5 or EagleSoft v17 or higher, your data is now encrypted. You will need to request a decrypted copy of data for conversion.

© 2022 Carestream Dental LLC.

All trademarks and registered trademarks are the property of their respective owners.
1