Phone *

(###)

###

####

Cancellation date

This is the date that your services will be discontinued. Service discontinuation means that you will no longer be able to log into your Asprodental portal. If you don't know the date yet, leave this field blank and you may inform us via email at the appropriate time. If you plan to extract your data, make sure this service cancellation date is AFTER the data extraction date.

MM

DD

YYYY

Data export date

Your data will be exported at the end of the day (around 9pm Pacific Time) on the date provided. Asprodental will provide your data in a standard data format (SQL) uploaded to a secure online folder. You will be given access to the folder via the email provided above. If you do not need your data exported, leave this field blank.

MM

DD

YYYY

Service cancellation *

By checking this box, I am authorizing Asprodental to cancel my practice management services on the date given above (or on a future date, once I provide the date). I am aware that once services are cancelled, I will not be able to log into my Asprodental portal and I will not have access to all the services within, including but not limited to text messaging, consent forms, e-claims, x-rays, etc.

Data release *

By checking this box, I am authorizing Asprodental to release my practice database to me in a standard data format, SQL. The data file will be uploaded to a secure Google Drive folder with access given only to the email provided above. I release Asprodental from any liability for my practice data once the folder's access has been released to me.

I refuse a data export. I understand that once my Asprodental services are discontinued, I will not have access to my practice data.

Name *

By providing my name below, I am certifying that I have the authority to make this cancellation and data release request on behalf of my dental practice.

First Name

Last Name