Easy Start Kit - WildSmiles Braces

New Provider Intake Form

*This form on average takes about 10 minutes to complete*

Step 1 of 3

Doctor Locator Listing & Co-Branded Marketing
Type below EXACTLY as you would like it listed and printed for our doctor locator and marketing items.
Practice Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Practice Name*
Practice Website*
Practice New Patient Phone Number*
Do you have additional locations?*
- Yes
- No
How many additional locations?*
2nd Location Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
2nd Location Phone
(optional)
2nd Location Practice Name
(optional)
3rd Location Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
3rd Location Phone
(optional)
3rd Location Practice Name
(optional)
4th Location Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
4th Location Phone
(optional)
4th Location Practice Name
(optional)
5th Location Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
5th Location Phone
(optional)
5th Location Practice Name
(optional)
6th Location Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
6th Location Phone
(optional)
6th Location Practice Name
(optional)
7th Location Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
7th Location Phone
(optional)
7th Location Practice Name
(optional)
8th Location Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
8th Location Phone
(optional)
8th Location Practice Name
(optional)
9th Location Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
9th Location Phone
(optional)
9th Location Practice Name
(optional)
10th Location Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
10th Location Phone
(optional)
10th Location Practice Name
(optional)

Practice Contact Information
Who should we work with to coordinate your onboarding and implementation?*
First Last
What is their email?*
What is their phone number?*
Must be a number we can text
Doctor Full Name*
First Last
Doctor Email*
Doctor Phone*
Must be a number we can text
Do you have an associate or partner doctors?*
- Yes
- No
Associate/Partner Doctor(s) Full Names*
Associate/Partner Doctor(s) Emails*
Associate/Partner Doctor(s) Phone Numbers*
Billing Contact / Accounts Payable Full Name*
First Last
Billing Contact / Accounts Payable Email*
Billing Contact / Accounts Payable Phone Number*
Treatment Coordinator Full Name*
First Last
Treatment Coordinator Email*
Treatment Coordinator Phone Number*
Do you have additional Treatment Coordinator(s)?*
- Yes
- No
How many additional TCs do you have?*
2nd Treatment Coordinator Full Name*
First Last
2nd Treatment Coordinator Email*
2nd Treatment Coordinator Phone Number*
3rd Treatment Coordinator Full Name*
First Last
3rd Treatment Coordinator Email*
3rd Treatment Coordinator Phone Number*
4th Treatment Coordinator Full Name*
First Last
4th Treatment Coordinator Email*
4th Treatment Coordinator Phone Number*
5th Treatment Coordinator Full Name*
First Last
5th Treatment Coordinator Email*
5th Treatment Coordinator Phone Number*
Marketing/Social Media Contact Full Name*
First Last
Marketing/Social Media Contact Email*
Marketing/Social Media Contact Phone Number*
Product Ordering Contact Full Name*
First Last
Product Ordering Contact Email*
Product Ordering Contact Phone Number*
If you have a Marketing/Website firm please provide their info below:
(optional)
Is your practice part of any DSO, OSO, or Buying Group?
If so, please tell us who the DSO, OSO, or Buying Group is.
How did you hear about us?*
Who can we thank for your referral?*

New Provider Intake Form

Step 1 of 3

Customize 15 of Your U2-2 Sets

Customize 10 of Your U3-3 Sets

Customize 36 of Your U2-2 Sets

Customize 25 of Your U3-3 Sets

Customize 60 of Your U2-2 Sets

Customize 60 of Your U2-2 Sets

Customize 40 of Your U3-3 Sets

Customize 40 of Your U3-3 Sets

Doctor Locator Listing & Co-Branded Marketing

Practice Contact Information