UOBG - United Orthodontic Buying Group

Complete the following signup form. It will then be submitted for review to see if you qualify to participate.

Prefix:

Practice Name:

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Yes, sign me up!

Address * :

Suite/Box:

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Dentsply Account Number:

My current Orthodontic supply company is:

If using GAC, what percent of GAC bands/brackets complete your appliance system?:

The name of the bracket/appliance system I currently use is:

Slot size:

I am now paying (per bracket):

I am now paying (per band/bracket combination):

I am:

a NEW GRAD

using a Grad Order Program

I was referred to/heard about UOBG from:

My office contact person is (name):

Please list other orthodontists currently in practice with you who wish to join UOBG.:

We have been very pleased with UOBG and the buying opportunities we receive.

Dr. Michele Laboda

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