Payment Processing Quote Request
Fill out this form, including uploading the office's processing statement(s) to request a quote from our payment processing partners.
eAssist Sales Team Member Info
Let us know who made the sale
Your Name
First Name
Last Name
Your Email
Dental Office Info
Tell us about the office's payment processing needs
Name of the Practice
Practice's Website
Dentist Name
First Name
Last Name
Point of Contact Name (if other than the Doctor)
First Name
Last Name
Business Phone Number
Dentist or Point of Contact Email
example@example.com
Office or Cell Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Payment Processing Info
Who is the practice's current credit card processor?
For how long?
How much do they charge?
What is your average monthly sales volume for credit cards?
What is your average Ticket Sale?
What percentage of your transactions are made using a card terminal?
What percentage of your transactions are made on your website?
Do you charge your customers a processing fee?
Yes
No
If you do charge a fee, what percentage? (leave blank if no)
Make and Model of your current Point of sale system or credit card terminal
Is your payment system integrated with your practice management software?
Yes
No
Which of the following features are you interested in?
e-Invoicing
Text-to-Pay
Advanced Fraud Alert (Prevent chargebacks before they happen)
ACH Transactions
Quickbooks Integration
Hosted Payments Page (taking payments on their website or app)
Customer Vault (for patient re-billing)
Any Additional Notes?
Upload their Processing Statement(s)
If you have multiple statements, upload them all before clicking "Submit"
File Upload
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