Dental Practice Referral Form
eAssist Employee Information
Enter your information so we know who earned the referral
Your Name
*
First Name
Last Name
Your email
*
Practice Information
Please enter the information for the referred dental office 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.
Format: (000) 000-0000.
Would the office like a custom quote?
*
Yes, they would like a custom quote
No, they are ready to move forward with standard pricing
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.
Upload Their Processing Statements Here (If you have them)
Browse Files
Drag and drop files here
Choose a file
Cancel
of
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 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?
Save
Submit & Schedule Appointment
Should be Empty: