NET30 Office Case Upload Net30 Upload (only) Dentist/Dental Clinic * Address * Address Address Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Phone * Email * Patient Name * First Name * Last Doctor Photo(s) Choose Photos Drop a file here or click to upload Choose File Maximum file size: 209.72MB Scan(s) Choose scan(s) Drop a file here or click to upload Choose File Maximum file size: 209.72MB A scan cleanup fee of $20 will be assessed for any cases requiring a scan cleanup. Lab Slip Instructions “e.g.” Shade, current date and Due Date * Submit If you are human, leave this field blank.
