At Valplast, we get a large number of enquiries from patients asking us to recommend a dentist.

If you process Valplast regularly, and would like to be a part of the Dentist Referral Network, please fill out the form below.

Once a member of our team has reviewed your entry (please note that we may need to contact you to ask a few more questions), they will place you onto our Database. This will then enable your practice to be a part of the geo-targeted lists that we will then give to patients when they are asking us for local dentists.

Name

Practice name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

Country

(###)

###

####

Email Address

Website

http://

Current Processing Laboratory

I authorize Valplast® International Corp. to distribute this information as a part of its Dentist Referral Network

Yes

I am aware of, and distribute the Valplast® Certificate of Authenticity to patients upon insertion of the finished partial.

Yes

Please send marketing materials to distribute to patients. (No charge)

Yes