COB Real Talk - Training & Workshop

COB Real Talk - Training/Workshop

Client Intake Form
Please complete the following form. Once received, we will reach out to schedule your complimentary Discovery Call.

For help completing this form or for more information:
1. Call: (980) 990-4071
2. Email: julie@practicebooster.com
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name*

First NameLast Name
What are your office hours?*
What is your time zone?*
What type of practice(s) do you have?*

General DentistryEndodonticPeriodonticProsthodonticOral SurgeryOrthodonticsOther
Please list the number of office locations and the corresponding zip code for each:*
List the insurance companies your providers participate with:*
What fee does your practice post to the patient's ledger?*

The Full Practice (Standard UCR) FeeThe Primary Contracted FeeThe Secondary Contracted FeeOther
What practice management software do you use?*
What clearinghouse do you use for sending electronic claims and attachments?*
Do you outsource your Insurance Verification or Dental Billing?*

YesNo
What company do you use?*
What are the Top 3 things you hope to gain from this training?*
*Practice Booster values your privacy! For more information on how we protect your information, please see our Privacy Policy.

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COB Real Talk - Training/Workshop