Instructions
To submit information for your specialist profile, please complete the form below and then, hit the Submit button. You can also upload a personal picture and a Doctor Referral Form. Send only the specific information that you want displayed on the DSI website. If you prefer to submit your information manually, please refer to Profile Guidelines.

This form is for dental specialists (doctors). Click here for the company upgrade form.

This Free Premium Profile upgrade will be effective from 3 days after the final profile approval and expires and expires 12 months after the effective date, unless other arrangements have been made. No payment or future obligation is required for this offer. Member is responsible to provide required information (indicated with an asterisk *) to complete the Premium Profile. Members must follow all guidelines, terms, and policies of DSI during the term of the membership agreement. See Terms.

NOTE: This Free Offer is non-transferable. This offer is limited and all completed forms must be submitted prior to the expiration date (see your email message for more details).
General Information
Doctor Title * (e.g., DDS, Dr.)
Doctor First Name *
Doctor Last Name *
StreeT *
City *
State *
Zip *
Telephone *
Fax
Email *
Website URL
Video URL (YouTube)
Social Media URL (Facebook)
Doctor's Picture / Referral Slip
Current Picture
High-quality JPG format, 115x150 pixels
Referral Slip
Office referral slip in PDF format (optional)
Office Hours
Office Hours
Submit Information


NOTE: Please send all content at the same time (e.g., completed form, picture, referral form). DSI retains final approval over all creative elements and profile content. Profiles must conform to DSI’s format/style, and must meet our content and grammatical standards.
Educational Background
Educational Background
Educational background (degrees and awarding schools)
Procedures, Treatments, and Services
Procedures, Treatments, and Services
Primary procedures, treatments, and services performed
Professional Activities and Memberships
Professional Activities and Memberships
Research and Publications
Research and Publications
Insurance Plans
Insurance Plans
List of accepted PPO/HMO Insurance Plans
Additional Personal Information
Personal Interests and Activities
Other Information
Other Information
Additional information not listed above that you want displayed (must meet DSI standards)