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LSA DENTIST FORM
LSA DENTIST FORM
Business Information
BUSINESS NAME
*
OWNER'S FIRST & LAST NAME
*
OWNER'S FIRST & LAST NAME
First
First
Last
Last
YEAR BUSINESS WAS FOUNDED
*
Email Linked to Google Business Profile
*
Password Linked to Google Business Profile
*
PROOF OF INSURANCE - PDF
*
Drop a file here or click to upload
Choose File
Maximum file size: 314.57MB
THE FOLLOWING IS NEEDED PER DENTIST
DENTIST FULL NAME
*
DENTIST FULL NAME
First
First
Last
Last
DENTIST EMAIL ADDRESS
*
SERVICES THAT THIS SPECIFIC DENTIST IS LICENSED TO PERFORM:
Bad Breath
Cavities
Chipped Tooth
Cracked Tooth
Crowns
Dental Checkup
Dental Implants
Dentures
Dry Mouth
Fillings
Gum Bleeding
Gum Disease
Missing Teeth Evaluation
Mouth Sores
Root Canal
Sealants
Teeth Cleaning
Teeth Whitening
Tooth Decay
Tooth Extraction
Tooth Infection
Tooth Pain
Tooth Sensitivity
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.
LICENSE
LICENSE NUMBER
IS THIS DENTIST A BUSINESS OWNER AND/OR SENIOR PARTNER?
YES
NO
WOULD THIS DENTIST LIKE TO BE FEATURED? (If yes, Please send a headshot)
YES
NO
SUBMIT HEADSHOT IMAGE (JPEG, JPG, PNG, TIFF)
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Maximum file size: 314.57MB
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PAYMENT INFORMATION / CREDIT CARD INFOMATION
Billing & Budget Information
BUDGET (Minimum is $306 / Week)
Please specify both the amount and timeline (example: $1,300 per Month)
ORGANIZATION NAME
CARD NUMBER
EXPIRATION
CVC
CARDHOLDER NAME
ZIP-CODE ASSOCIATED WITH THE CARD
If you are human, leave this field blank.
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