First Name *

Last Name *

Phone *

Email *

Legal Business Name *

Please double-check, we use this name to get A2P approved.

Business Short Name *

Friendly name

Business Entity Type *

EIN (US) / CCN (Canada ) Number *

We use this number to get A2P Approved

What describes your office the best? *

What are your office hours for scheduling appointments? *

Enter the hours when appointments can be scheduled at your office.

What should we include in your offer? *

Select all the services or items you want to include in your offer. Select None if you do not want to include any of the listed options.

What additional offers or promotions should we feature in your campaign? *

Enter any additional offer or promotion that is not listed above. If you have nothing else to add, enter "None."

Website link *

Doctor's First Name *

Doctor's Last Name *

Doctor's Gender *

Doctor's Years of Experience *

Doctor's WhatsApp Number *

Doctor's Email Address *

Office Manager Name *

Office Reception Number *

Office Email Address *

Enter the email address for Google Sheet access *

Enter the email address that should receive access to the Google Sheet containing your patient show-up records.

Enter the team email addresses for Slack invitations *

Enter the email addresses of the team members who should be invited to your Slack channel. We'll use this channel to share booked appointments and important updates. Add one email address per person, separated by commas.

Which Dental / Practice-Management System Do You Use? *

Dental System Details for Direct Booking *

List the column names from your dental software that you want us to connect. This is shared, not exclusive, you keep booking as usual, we just book alongside you. The more columns you share, the more openings we can see and fill appointments.

PPO Insurances *

can select multiple options. please select "None" if nothing is applicable"

HMO Insurances *

can select multiple options. please select "None" if nothing is applicable"

Medicare Insurances *

can select multiple options. please select "None" if nothing is applicable"

Essential Plans Insurances *

can select multiple options. please select "None" if nothing is applicable"

Other Insurances / Reimbursements (if any)

Street Address *

Make sure the Address exactly matches the Google Profile address of the office.

City *

State *

Country *

Postal Code *

Landmark *

Which campaign did you sign up for with us?

Choose the campaign you signed up for. We use this to setup everything correctly for your practice.

How long do you plan to keep the consultation for? *

The appointment length we book for each patient.

What does a patient pay for a complete Invisalign treatment? *

Enter the total treatment cost for one patient. Enter NA if not applicable.

If you offer a payment plan, how much does a patient typically pay per month for Invisalign? *

Enter the monthly amount for your standard payment plan. Enter NA if not applicable.

If you offer a co-signer option, how much does a patient typically pay per month for Invisalign? *

Enter the monthly payment when a co-signer guarantees the plan. This amount is typically lower than the standard payment. Enter NA if not applicable.

What does a patient typically pay for one denture arch? *

Enter the typical cost for a single arch (top or bottom). A price range is fine. Enter NA if not applicable.

With insurance, what is the lowest a patient could pay for one denture arch? *

For US offices, enter your in-network rate. For Canada, enter what a CDCP patient pays. Enter NA if not applicable.

If you offer a payment plan, how much does a patient typically pay per month for dentures? *

The monthly amount on your standard payment plan. A price range is fine. Enter NA if not applicable.