Community Partner Form
Thank you so much for being in our network of trusted community partners! We would like to easily refer patients back and forth, so they know where to go for quality care. Our hope is by creating a community partners page on our website that we can support each other's businesses while providing patients with needed resources.
Once we have shared mutual patients we would like to feature you on our website as a trusted community partner. If you would like to accept, please provide the following information. Thank you again, we look forward to continued collaboration and helping patients thrive!
Have we shared any mutual patients yet? If so, do you know their names?
Name
First Name
Last Name
Business name
If more than one practitioner is in the practice, please list the other providers here:
Social media handles for instagram and facebook
Email you would like patients to use to contact you
example@example.com
Business Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Do you offer in-home visits?
yes
no
Do you offer telehealth appointments?
yes
no
How do you prefer patients contact you?
Phone Number for patients to call
Please enter a valid phone number.
What age groups do you treat? Please check all that apply
pre-crawling infants
infants (0-1)
toddlers (1-4)
children (4+)
adults (18+)
other (please specify)
Which category would you like to be listed under?
IBCLC/CLC/Lactation
Chiropractor
midwife
occupational therapist
osteopath
Physical Therapist
CST
Speech Language Pathologist
Pelvic Floor Specialist
Myofunctional Therapist
Functional/Integrative Medicine Provider
Other
How do you prefer to receive information from our office?
encrypted email
fax
text
call
Please detail who is the best point of contact in your office, who to request patient information from, and how is easiest to discuss shared patients. Dr. Shannon likes to stay in touch by texting on personal cell and drshannon@wellspringdentalatl.com email when possible, but also wants to create office systems for when she's not able to be the point of contact for time sensitive matters. Email does allow for easier access for accessing case information in the future, but text is better when we need to go back and forth a few times.
Please submit a photo for the website (optional)
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of
website
Please provide a brief description of what you do for our website
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