by Capital One®

 

If you are a dentist, and want to lower your costs, increase case acceptance, and improve access to the benefits of mini dental implants, fill out this simple form to get started today!








Specialty:

Name of Primary office contact (OM, FC, TC):

Business Address:

City:

State:

Zip Code:

Business Phone:

Fax:

Email:

Business Web Site:

Do you want to be listed on minidentalimplants.com?

We routinely provide announcements about new programs and products to our practices. We will contact you using the information provided above. Please indicate if you do not wish to be contaced in one of the following ways:

Fax E-Mail Other:

Annual Production:

Average Case Fee:

# of Patients starting treatment per week:

Do you offer a discount for payment in full? If yes, what percent?

Do you compensate your staff on production of volume?

Do you currently use third party financing, if yes, who?

% of volume expected through financing


Please identify the importance of the following features on your decision to use a patient financing option in your practice by selecting the approprite selection.

Low Patient Intrest Rate

Brief, Easy Application Process

Practice Support / Service

Quick Application Decision

High Approval Rate

Attractive Patient Materials

Low Administrative Fee to Practice

High Patient Customer Service