Internal Referral Form

Internal Referral Form

Internal Employee Use Only
Send a referral to eAssistSend a referral to UnitasSend a referral to Practice Booster
First, Tell Us About You

Let us know who you are, so we can get you paid ;-)
What's Your Name?*

First NameLast Name
Your Email?*
Should be @eassist.me or @unitasdental.com or @practicebooster.com
ATTENTION: This form should only be used for sending a referral to a different company, if you work for the company you're sending the referral to. Don't use this form.

For Unitas employees looking to send a referral to unitas; email RaNae at pposolutions@unitasdental.com

For eAssist employees looking to send a referral to eAssist; email sales@eassist.me
Then, Tell Us Who You're Referring

Please enter the referral information below
Practice Name*
Lead's Name*

First NameLast Name
Lead's Email*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Dental Insurance BillingInsurance VerificationPatient Billing ServiceFull Schedule ReviewDental Accounting & BookkeepingEFT Reconciliation
PPO Negotiations & OptimizationPPO Credentialing
Dental coding & administration - booksDental coding & administration - digital resourcesCE courses and webinarsRevenue Enhancement ProgramCoordination of Benefits TrainingSpeaking or other consulting
Main Practice Address (OLD)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Main Practice Street Address
Main Practice City
Main Practice State*
Main Practice Zip Code
eAssistUnitasPractice Booster
Edit the email message below, this message will auto-email to the lead and {companyReceiving}, once you click submit:*
Hi [LEAD NAME],

I wanted to introduce you to the [COMPANY NAME] team. You and I have spoken about your interest in their services so I wanted to make the introduction. Someone from their team will reach out soon to help you setup a consultation.

Thank you!

[YOUR NAME]
Commission Terms:

Employee must be employed by the applicable company at the time of commission payment to be eligible to receive payment.

Commissions will be paid Quarterly in the following Quarter after the sale was received.

If two or more employees refer the same elead, prior to the lead closing on services, the 1st referring and last referring reps will split commission. 1st referring rep's referral must be less than 6 months, otherwise the last referring rep will receive full commission.
Should be Empty:

Internal Referral Form

First, Tell Us About You

Then, Tell Us Who You're Referring