Dental Practice Quote Request Form
First, Tell Us About You
Your Name
*
First Name
Last Name
Your email
*
Then, Tell Us Who You're Referring
Please enter the referral information below
Name of the Practice
*
Practice's Website
Doctor's Name
*
First Name
Last Name
Point of Contact Name (if other than the Doctor)
First Name
Last Name
Doctor or Point of Contact Email
*
example@example.com
Office or Cell Phone Number
*
Please enter a valid phone number.
Upload Their Processing Statement(s) Here
Browse Files
Drag and drop files here
Choose a file
We need to see a recent processing statement so we can show the dental practice how much money they'll save.
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That's Everything We Need For The Referral. Thank you!
Below are some additional questions. They are not required, but they are helpful if you know the answers. If you don't, just hit the "Submit" Button.
How do they usually accept credit cards? (select all that apply)
Card Reader Terminal
POS System (usually a touchscreen, like an iPad)
Keyed in on the computer
Online Patient Portal
Other
How many card reader terminals does the practice currently have (if any)?
Please Select
Just 1
2 or more
None. We type them into the computer manually
Please call me for details on equipment
Any Additional Notes?
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Submit & Schedule Appointment
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