Comfort Dental is the largest dental franchise in America. All of our locations are independently owned and operated. If you are a dentist or a 3rd or 4th year dental student, and you’re interested in owning your own Comfort Dental office, please fill out the below form and we will reply with more information. Thank you for visiting Comfort Dental.

Potential Partner Orientation & Disclosure

Name *	Prefix	First *	Last *	Suffix
Date of Birth *	01 02 03 04 05 06 07 08 09 10 11 12 MM / 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 DD / 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 YYYY
Marital Status *
Cell Phone *	### - ### - ####
Work Phone *	### - ### - ####
Email *
What STATE(s) are you/will you be licensed to practice in? *
What dental school did you attend? *
What year did you graduate, or what is your projected graduation? *
Are you currently in private practice? *
	yes   no
What is your current employment status? *
Do you have a practice to sell? *
	yes   no
If you are an Associate, when does your current contract expire? *
What undergraduate school did you attend, and what year did you graduate? *
What state(s) interest you most to practice dentistry? *
How did you hear about the Comfort Dental opportunity? *
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