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First Name *
Dr.

Last Name *

AGE *

SEX *

YEAR OF GRADUATION *

NAME OF DENTAL COLLEGE OF GRADUATION

YEAR OF POST GRADUATION

NAME OF DENTAL COLLEGE OF POST GRADUATION

DCI REGISTRATION NO. *

PRACTICE NAME

PRACTICE ADDRESS

ARE YOU PROVIDING ALIGNERS TO YOUR PATIENTS

CITY *

PINCODE

STATE/UT

MOBILE *

EMAIL ID

AREA OF SPECIALIZATION

your DCI registration certificate

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COST OF TREATMENT WITH METAL BRACKETS (MENTION PRICE RANGE)
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COST OF TREATMENT WITH CERAMIC BRACKETS (MENTION PRICE RANGE)
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COST OF TREATMENT WITH LINGUAL BRACKETS (MENTION PRICE RANGE)
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