Slash Dental Customer Intake

It's time to Slash your dental bill. Tell us more about it.
Name of Dental Practice*
Please give us the name of the dental practice, not the specific dentist you saw
When did you receive care?

MonthDayYear
If you want us to negotiate cost on an upcoming procedure, leave this blank
Address/Location of Dentist*
We need at least the city and state
In addition to looking for cost savings (which we do automatically), are there any specific issues regarding your dental bill you want us to help with?:

I got charged for a procedure I did not getI took on debt with a third party I cannot afford to payI got charged for the wrong procedureI cannot afford the amount I was chargedI need more time to pay my billMy insurance should be paying more for my billOther

We need a little bit of info about you (or the patient) to action ...
Patient Name*
If you're a parent or guardian filling this out on behalf of someone, use their name not yours!
Best Contact Email*
Patient Date of Birth*

MonthDayYear
If you're a parent or guardian filling this out on behalf of someone, use their birthday not yours!

We're ready to find savings on and/or fix your dental bill. Now we just need your permission to do so.
Sign here to agree to the above terms & conditions, including the Authorization to Negotiate and temporary, limited HIPAA waiver required to negotiate with third parties on your behalf.*
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It's time to Slash your dental bill. Tell us more about it.