POD Certified Provider Enrollment

POD Certified Provider Enrollment

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Welcome		Provider Details		Practice Details

Please complete the following form to be listed as a POD Certified Provider and to receive mailing materials to your office. Immediately upon completion of this form, you will also receive a link to the following materials:

1. Prescription Form
2. Appliance Submission Instructions
3. Video Recording of the Certified Provider Course
4. Screening Questionnaires and Evaluation Forms
5. Link to the Chimera App (to determine appliance design)

NOTE: Please enter your name and credentials as you wish them to appear on the Certified Provider Accreditation certificate (sample below).

PROVIDER INFORMATION
Name
N/A

Required First Required Last
Credentials *
N/A

(i.e., DDS, DMD, MS, PhD, etc)
Your Personal Email *
N/A
State License Number
N/A

PRACTICE DETAILS
Practice Name
N/A
Address
N/A

Required
Street Address
Address Line 2 Required City Required State/Region/Province Required
Postal / Zip Code

Country
Practice Phone Number
N/A
Practice Email
N/A

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