Customer Order Form - WildSmiles Braces

Order Form

*This form on average takes about 15 minutes to complete*

Step 1 of 3

Step #3 - Payment, Billing, Shipping, & Contact Information
Grand Total
Price: $0.00
Coupon Code
Practice Name*
Invoice Email*
Enter Email Confirm Email
Payment Information*
- Charge Card on File
- Update/Charge New Card
CC Last Four Digits*
CVV*
Credit Card Number*
Expiration Month*
Expiration Year*
CVV*
Zip Code*
Please enter your ZIP code: 5 digits for the United States or 6 characters for Canada.
Do we need to update any of your information on file?*
- Yes
- No
Billing Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Shipping Address (if different from billing)
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Update Practice Contact Information
Who should we work with to coordinate your onboarding and implementation?
First Last
What is their email?
What is their phone number?
Must be a number we can text
Doctor Full Name
First Last
Doctor Email
Doctor Phone
Must be a number we can text
Do you have an associate or partner doctors?
- Yes
- No
Associate/Partner Doctor(s) Full Names
Associate/Partner Doctor(s) Emails
Associate/Partner Doctor(s) Phone Numbers
Billing Contact / Accounts Payable Full Name
First Last
Billing Contact / Accounts Payable Email
Billing Contact / Accounts Payable Phone Number
Treatment Coordinator Full Name
First Last
Treatment Coordinator Email
Treatment Coordinator Phone Number
Do you have additional Treatment Coordinator(s)?
- Yes
- No
How many additional TCs do you have?
2nd Treatment Coordinator Full Name
First Last
2nd Treatment Coordinator Email
2nd Treatment Coordinator Phone Number
3rd Treatment Coordinator Full Name
First Last
3rd Treatment Coordinator Email
3rd Treatment Coordinator Phone Number
4th Treatment Coordinator Full Name
First Last
4th Treatment Coordinator Email
4th Treatment Coordinator Phone Number
5th Treatment Coordinator Full Name
First Last
5th Treatment Coordinator Email
5th Treatment Coordinator Phone Number
Marketing/Social Media Contact Full Name
First Last
Marketing/Social Media Contact Email
Marketing/Social Media Contact Phone Number
Product Ordering Contact Full Name
First Last
Product Ordering Contact Email
Product Ordering Contact Phone Number
Signature*
Please sign if all information is correct

Order Form

Step 1 of 3

Step #1 - Choose Brackets

The Signature Collection

The College Collection

The Disney Collection

Bracket Total

Step #2 - Choose Elastics

Elastics Total

Step #3 - Payment, Billing, Shipping, & Contact Information

Update Practice Contact Information