Dr. Order Form

Doctor's Information Sheet for Fundent Brochure and Gift Certificate.

When filling out the following form:
It is important to use your TAB key or MOUSE to move from line to line.
Do Not Use Enter Key - as it will send an incomplete form.

Name of Doctor

Name of Practice

Street Address

Address (cont.)

City

State

Zip/Postal Code

Office Phone

Fax

E-mail address

Practice Web Site Address

Type of Practice
General; Pediatric; Ortho; Other

Days of operation

Hours of operation

First time use of Fundent
Yes No

Dollar amount to be placed on Gift Certificate for this order

Name to be used on Front and Back of Gift Certificate

Address to be used on Back of Gift Certificate

Phone number to be used on and Gift Certificate

What type of pictures does Dr. want on Brochure
Choose only one: Dr.; Office; Staff; Other

Name to be used on Front and Back of Brochure

Address to be used on Back of Brochure

Phone number to be used on Brochure

What written information does Dr. want on Brochure?
Note: This should be limited to 150 words or less as space is limited to front of Brochure.

Any changes to standard Gift Certificate Language or Other special information:
If yes, then be specific about changes.

Note: Resolution requirements for all pictures:
1600 x 1200 pixels 5.3" x 4" @300 dpi min
2400 x 1800 pixels 8" x 6" @ 300 dpi Max.

Please Note: All Brochure and Gift Certificates shall be sent in draft form to the doctor for approval prior to actual printing.

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Name of Doctor
Name of Practice
Street Address
Address (cont.)
City
State
Zip/Postal Code
Office Phone
Fax
E-mail address
Practice Web Site Address
Type of Practice General; Pediatric; Ortho; Other
Days of operation
Hours of operation
First time use of Fundent Yes No
Dollar amount to be placed on Gift Certificate for this order
Name to be used on Front and Back of Gift Certificate
Address to be used on Back of Gift Certificate
Phone number to be used on and Gift Certificate
What type of pictures does Dr. want on Brochure Choose only one: Dr.; Office; Staff; Other
**Name to be used on Front and Back of Brochure**
Address to be used on Back of Brochure
Phone number to be used on Brochure