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Fee Report RequestFee Report Request

Thank you for your interest. Once you have submitted this form, a member of our team will contact you with your analysis. If you have questions in the interim, please feel free to contact us at or (800) 262-4119.

Note: Please complete the entire form. The information will only be used by Henry Schein Professional Practice Transitions and is not to be transferred to any other party.

  Your Name:

  Year you Started Practicing:
  Sq. Footage of your Office:
  Number of Operatories:
  City of Your Practice:
  Zip Code of Your Practice:
  Preferred Phone Number:
  Preferred Email Address:
  Your Dental Specialty:
  In the next five years, I plan to:

  Please contact me about:

  How you found
  ADS Florida eNewsletter*:
  Questions or Comments:

* we do and will not share our e-Newsletter list with any third party.



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