Slash Dental Customer Intake
Take 5-10 minutes to fill out the below ... and then let's get you a better deal on your dental bill!
What is the name of the dental practice who serviced you?
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Please give us the name of the dental practice, not the specific dentist you saw
When did the dental services at issue occur?
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Month
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Day
Year
Date
Where is your dentist located? (Provide at least city and state, preferably full address)
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Patient Name
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If you're a parent or guardian filling this out on behalf of someone, use their name not yours!
Patient Date of Birth
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Month
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Day
Year
If you're a parent or guardian filling this out on behalf of someone, use their birthday not yours!
Best Contact Email
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What services were performed during the dental visit in question?
Telling us what you think happened at the appointment can help uncover potential billing errors. But skip this if you don't remember or think the bill speaks for itself.
Please upload a copy or photograph of the dental bill at issue here, along with any other documentation you think is relevant.
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Files must be less than 10.8GB combined.
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Please check what you'd like us to review/assist regarding the dental bill submitted above (select all that apply):
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I got charged for a procedure I did not get
I took on debt with a third party I cannot afford to pay
I got charged for the wrong procedure
The charges on my bill are too expensive relative to fair prices
I cannot afford the amount I was charged
I need more time to pay my bill
My insurance should be paying more for my bill
Other
If possible, please provide more details/specifics on why you checked the boxes above as issues with a dental bill:
Sign the Permission to Negotiate form here.
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Sign the partial and temporary HIPAA waiver here.
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Submit
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