Advertising Request

I authorize CostaRicaDentalGuide.com and GuíaDentalCostaRica.com to promote our clinic on the aforementioned websites at no charge.

Owner's Name *

First

Last

Cédula (Personal o Jurídica) N°: *

Address: *

Clinic Name *

Clinic Phone *

Contact Email for Clinic *

Website / URL

Brief Description of Business

Legal Representative

Name of Legal Representative: *

First

Last

Cédula *

Phone of Legal Representative *

Authorization

1. I declare that all the information noted above is true.

2. I authorize you to show the clinic’s advertisements free of charge and through both websites.

3. I authorize the use of the name, commercial logo, and business photos.

4. I authorize the use of the information given for a term of 5 years with an option for another 5 years, if neither party requests the termination of said contract.

5. I commit to send the logo, photos and descriptions of the Clinic to the email care@costaricadentalguide.com.

6. I understand that patients can leave reviews about my clinic. I authorize CostaRicaDentalGuidecom and GuiaDentalCostsaRica.com to publish the reviews.

Photos can be posted *

Languages managed by the staff: (mark all that apply) *

Español
English
Other

File Upload: Upload logo and photos

Click or drag files to this area to upload. You can upload up to 5 files.

Up to 5 images can be sent.

By submitting this form, you authorize Costa Rica Dental Guide and Guia Dental Costa Rica to use the information you have provided. *

Email care@costaricadentalguide.com to reach one of our patient advocates and to learn more about affordable dental care in Costa Rica.

I authorize CostaRicaDentalGuide.com and GuíaDentalCostaRica.com to promote our clinic on the aforementioned websites at no charge.

Legal Representative

Authorization

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