Your practice details

Tell us about your practice so we can set up your Digital Reactivation campaign. Fields marked * are required.

1. Practice information

Legal Business Name (Exact EIN Registered Name) *

DBA / Practice Name (Public-Facing Name) *

Is this an additional location of a practice that's already a client? *

No, it's their first location

Yes, their 2nd location

Yes, their 3rd location

Yes, their 4th location or more

Business Type (LLC, Corp, Sole Prop, etc.) *

LLC

Corporation

Sole Proprietor

Other

EIN (Required for SMS registration) *

Practice Address (Full Street Address) *

Website URL

Privacy Policy Link *

Terms & Conditions Link *

Main Office Phone Number (for call forwarding) *

Time Zone *

Industry (Confirm: Dentist / Healthcare) *

Dentist

Healthcare

2. Authorized representative

Authorized Representative First & Last Name *

Title (Owner / Office Manager / Admin) *

Direct Email (Professional Domain Preferred – NOT Gmail) *

Direct Phone Number *

3. SMS consent & compliance

How do you currently collect SMS consent? *

Paper forms in office

Digital forms on website

Both

Other

Upload a screenshot or copy of your patient SMS consent form *

Do patients explicitly check a box agreeing to receive text messages? *

Yes

No (we need to implement this before launch)

Do you send messages to Canadian numbers? *

No (default)

Yes

4. Doctor & branding

Primary Doctor Last Name (as it should appear in texts) *

5. Phone setup

Should reactivation calls forward to: *

Main office line

Direct scheduling line

Call center

Other

If Other, where should calls forward to?

Does your phone system use an IVR menu (Press 1 for scheduling)? *

Yes

No

Do you want Call Recording enabled? *

Yes

No

6. Patient list

What practice management software do you use? *

EagleSoft

Dentrix

Open Dental

Other

Age restrictions? *

18+ only

Pediatric practice

Custom

If Custom, what is the age restriction?

7. Campaign settings

Preferred Sending Days & Hours

8. Lead handling

Who should receive internal notifications when a patient replies YES? (Name + Email) *

Who is responsible for calling leads within 24 hours? *

9. Client portal access

Business Email for Login Creation (Must contain business name) *

This is a test

Privacy Policy