Software Registration

Please fill in all fields on this form. This information will NEVER be sold or given to any other company. After completing this form you will be able to download the software. In addition, we will mail a CD-ROM with the demo software and a 25 minute demo movie to the address you specify below. Please complete the address carefully. Or, send an email message to sales@ace-dental.com or call 888-667-4272 if you would like to receive the demo movie on VHS tape. All completed forms will be entered in our monthly drawing for a FREE prize.

Name:
Address1:
Address2:
City:
State:
Zip:
Country:
Phone:
Fax:
EMail:
Specialty:
Office Mgr. Name:
Do you want to file Electronic Insurance Claims?: Yes No
Number of claims per month:
Number of patient statements sent per month:
Model: Windows Mac
Do you currently have dental software?: Yes No
If so, what software company?:
I am a: Dentist Office Manager Dental Staff Consultant Potential Sales Rep
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