Skip to content
Close
Open
Home
About Us
Our Labs
Blue Box
C.A.C.
Knight
Leixir New York
Precision
Thompson
York
IOS Programs & Training
Digital Dentures
DSO Lab Services
Implant Products & Services
MyLabConnect (MLC) – Customer Portal
Clinical Education
Photo Gallery
Video Gallery
Careers
Contact Us
Send a Case
Customer Bill Pay
New Account Form
Practice Information
Company (Practice) Name
(Required)
Company (Practice) Legal Name (if different)
Parent Company (Optional)
Practice NPI II Number
(If not available, click on
NPPES NPI Registry
):
Practice Code (Office Location # / Epicore ID)
Practice Email Address
(Required)
Practice Phone Number
(Required)
Practice Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Billing Information
Name
First
Last
Email
Phone
Payment preferences
Auto-Pay
Online-Pay
Check
Call For Payment
Other
Special instructions: (i.e. group consolidated statement, invoice frequency)
Customer Type
DSO Name (if applicable)
(Required)
GPO Name (if applicable)
Customer Class (Speciality)
General Dentistry
Pediatric Dentistry
Orthodontics
Endodontic
Prosthodontics
Other
Fee Schedule
DSO
Default
Special Pricing
IOS Platform
Dexis/Carestream
Heron (3DISC)
iTero
Medit
Planmeca
Primescan/Sirona
Shining 3D
SIRIOS
Trios
Other
Additional Instructions for account set-up
Dentist Information
Name
(Required)
First
Last
NPI I Number (Dentist)
(Required)
(If not available, click on
NPPES NPI Registry
):
License #
Primary Leixir Lab
(Required)
Choose Primary Lab
4G Dental Lab
Blue Box Dental Lab
C.A.C. Dental Lab
EassyDent Dental Lab
Knight Dental
NXT LVL Dental Lab
Precision Craft Dental Lab
Showcase Denbal Lab
Thompson Suburban Dental Lab
York Dental Lab
Dentist Preferred Method of Communication
(Required)
Text
Call
Email
Dentist Email Address
(Required)
Dentist Phone
(Required)
Does dentist practice at multiple locations?
Yes
No
Other Locations
Address
Zip
Practice NPI II Number
Add
Remove
Dentist Specialty
General Dentistry
Pediatric Dentistry
Orthodontics
Endodontic
Prosthodontics
Other
Dentist Notes
Dentist Trial Success Criteria
How Did Dentist Learn About Leixir?
Live Event/Tradeshow
Clinical Education Webinar
Peer Referral
In-Office Training
Rep Visit
Other
Other Way Dentist Learned About Leixir
(Required)
Why did dentist select Leixir?
How many cases does dentist intend to send to Leixir in next 2 months to assess satisfaction?
Fixed Cases
Implant Cases
Removable Cases
How will dentist measure success (i.e. specific expectations on quality, fit, turnaround time, communications, etc.)?
Is dentist interested in any of the following Leixir clinical education programs?
Select All
General Restorative
Digital Dentures
IOS (Crown and Bridge
Implants
Scanning for Edentulous Arches
Δ