Apply to Participate

Completion of this checklist is required prior to receiving referrals. Submission does not imply automatic acceptance.

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Practice Name: *

day financing referral

Location(s) *

Website URL: *

Primary referral contact name: *

Contact Email: *

Contact Phone: *

Digits only (no dashes). Example: 3525551234

Services Offered *

• Dental Implants
• Mini Dental Implants
• Implant-supported dentures
• Same-day/expedited options

We have a designated contact for implant referrals *

• Yes
• No

We can contact referred patients within one business day *

• Yes
• No

We respect patient contact preferences *

• Yes
• No

We explain consultation steps clearly *

• Yes
• No

We inform patients about financing availability *

• Yes
• No

We communicate scheduling changes promptly *

• Yes
• No

We provide appropriate follow-up after consultation *

• Yes
• No

We use a refundable consultation deposit or attendance confirmation *

• Yes
• No

We have experience with patients traveling from outside our immediate area *

• Yes
• No

Acknowledgement *

• We understand that referral participation is based on adherence to these standards and may be reevaluated.

Submit