LSA DENTIST FORM

LSA DENTIST FORM

Business Information

OWNER'S FIRST & LAST NAME
OWNER'S FIRST & LAST NAME
First
Last
Maximum upload size: 314.57MB

THE FOLLOWING IS NEEDED PER DENTIST

DENTIST FULL NAME
DENTIST FULL NAME
First
Last
SERVICES THAT THIS SPECIFIC DENTIST IS LICENSED TO PERFORM:
By selecting one of these services, you confirm that this dentist carries relevant licenses required to perform work offered and booked through the Local Services Ads platform at all times. Per Google’s Minimum Provider Requirements, You are solely responsible for maintaining compliance with applicable law, regulations, and licensing requirements in each jurisdiction where you provide services. Google LLC may request proof for a relevant license or registration from you at any time. Failure to provide proof of valid licenses or registrations may cause your ad to pause.
IS THIS DENTIST A BUSINESS OWNER AND/OR SENIOR PARTNER?
WOULD THIS DENTIST LIKE TO BE FEATURED? (If yes, Please send a headshot)
Maximum upload size: 314.57MB
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PAYMENT INFORMATION / CREDIT CARD INFOMATION

Billing & Budget Information

Please specify both the amount and timeline (example: $1,300 per Month)