Refer a Business/Group to the Dental Benefit Program

REFERRAL INFORMATION:
Business/Group Name (required)

Address, City, State Zip of Referral

Approximate Number of Employees

Referral Contact Name

Referral Contact Title

Referral Contact Phone

Referral Contact Email

Have you already had a conversation with this contact about the Dental Benefit program?

NoYes

Additional Notes and Details:

YOUR CONTACT INFORMATION:
Your Practice Name (required)

Your Name (required)

Your Title

Your Email

Your Phone (required)

Are you a Dental Cooperative member?

NoYes

Once submitted, we will contact the organization about participating in the Dental Benefit Program. If this organization joins the program, your practice name will be included on the back of the DBP card as a referring dentist along with a URL to see all other participating dentists in the DBP.