For dental practices · register once

Register your practice.

Five minutes, once. Then every request is one tap from your phone, and the $75 placement fee is charged to your saved card only once an assignment is completed.

Step 1 of 4Your practice

Practice legal name *

DBA (doing business as)

Street address *

City *

State

ZIP *

Practice phone (gets texts) *This is the number your one-tap link and assignment texts go to.

Office manager *

Office manager cell

Office manager email (receipts) *

Dentist of record *

Dentist DDS license number *

Practice business license (optional)

Dentist pocket license (optional)

Member discount

Members of these groups pay $65 instead of $75 for their first 3 assignments. We verify membership before the discount starts. Not valid with any other promotions.

Bay Area Networking for Dental Professionals (Facebook group)Partnership Study ClubContra Costa DPLN (office manager is a member)

Promo code (optional)Have a code from Aligned? Enter it here. Only one discount applies per assignment, and we use the best one.

Step 2 of 4W-9

Fill it in onlineSame fields as IRS Form W-9Upload a signed W-9PDF

1. Name of entity/individual (as shown on your income tax return) *

2. Business name/disregarded entity name, if different

3a. Federal tax classification *

LLC tax classification (C, S or P)

Other (describe)

3bCheck if you are a partnership, trust or estate with foreign partners, owners or beneficiaries.

4. Exempt payee code (if any)

4. Exemption from FATCA reporting code (if any)

5. Address (number, street, and apt. or suite no.) *

6. City, state, and ZIP code *

7. List account number(s) here (optional)

Part I. TIN type *

Taxpayer identification number *

Certification item 2Check only if the IRS has notified you that you are currently subject to backup withholding (this crosses out item 2).

Part II. Certification

Under penalties of perjury, I certify that: 1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and 2. I am not subject to backup withholding because (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding; and 3. I am a U.S. citizen or other U.S. person; and 4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.

Sign the W-9I certify the statements above under penalties of perjury, and typing my name below is my signature.

Signature of U.S. person (type your full name) *

Your TIN is stored privately. Our admin screen only ever shows its last 4 digits.

Step 3 of 4Practice agreement

Loading the agreement…

I agreeI have read and agree to the Dental Practice Contract for Staffing Services on behalf of the practice, I am authorized to sign for it, and typing my name below is my electronic signature.

Type your full name to sign *

Next: save a card. Nothing is charged today.

Register your practice.

Step 1 of 4Your practice

Step 2 of 4W-9

Part II. Certification

Step 3 of 4Practice agreement

Step 4 of 4Save a card