Network Application Form

1. Clinic Details
2. Company Details
3. Principals & Other Stakeholders

I wish to apply to join All On 4 Plus® network as (choose one per location):

All On 4 Plus® Associate (Premium Provider)
This is a franchise structure (refer to the Information Statement) which is only offered to suitable candidates who are interested in a more comprehensive involvement within the All on 4 Plus® brand using the brand’s intellectual property and undertaking training with Dr Fibishenko or senior associates within the network. The dentist may be restorative or surgical or both. There is a commitment to a marketing spend (which is commissioned on behalf of the network), annual fee (which may be annulled depending on the level of referral to senior associates within the network), and a $950 monthly website/portal/1300 maintenance fee. There are many benefits as well as various requirements and responsibilities subject to a comprehensive Franchise Associateship Agreement. The clinic will identify as All On 4 Plus® Premium Provider.

All On 4 Plus® Affiliate
Suitable for dentists or prosthetists who wish to be involved in some or all of the restorative components of All On 4 Plus® treatments and otherwise refer the surgical component to an Associate within the network. The clinic will be licensed to use the trademark and identify as All On 4 Plus ® Affiliate. There is a $350 monthly fee for portal access and directory listing, but otherwise no commitment to marketing and no annual fees subject to maintaining a minimum of 5 referrals per year and the terms of an Affiliate License Agreement.

Trademark Licensee
Fixed Annual fee of $11,600 per clinic location allowing limited use of the trademark only (excluding use within a business name or as a descriptor), subject to the terms of a License Agreement.

1. Clinic Details

Clinic Name:

Clinic Location Address:

Please indicate which applies:

This is a pre-existing practice

This is a new/prospective clinic, if so when do you anticipate commencement?

Clinic website/s:

(leave blank if no existing websites)

Clinic Contact Email:

Clinic Contact Number:

Clinic Description:

Please provide a description of the clinic such as information about the space, age of the clinic, the equipment, its clients/demographic, types of treatments, the clinics and/or principal’s focus and any other information which may be useful in support of your application.

Are you planning to renovate or expand in the near future, if so provide details?

Are you interested in setting up GA facilities, if so do you have (or plan to build) a room of minimum dimension 4.5m x 5.5m which can be used as theatre, and another separate room which can be used for recovery? Please provide details.

Approximate area (dental/clinical) in square metres

Approximate area (laboratory) in square metres (if any)

Brand/s of dental chairs

Number of dentists

Number of chairs

Number of staff

Brand of Cone Beam (if any)?

Brand of Digital Intra-oral Scanner/s (if any)?