CREATE A CUSTOM PATIENT PROGRAM

*required

Step 1) Practice Information:

PRACTICE NAME*

NAME OF PRIMARY DENTIST*

NAME OF EMPLOYEE RESPONSIBLE FOR YOUR CUSTOM PROGRAM*

EMAIL OF EMPLOYEE RESPONSIBLE FOR YOUR CUSTOM PROGRAM*

COOPERATIVE ACCOUNT# (Found on Invoice. Optional)

Step 2) Shipping Address For Your Cards:

ADDRESS*

SUITE

CITY*

STATE*

—Please choose an option—ALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY

ZIP*

Step 3) Program Information:

YOUR PROGRAM NAME*

Ex: Dr Smith Dental Club, Big Smiles Senior Plan, etc.

WELCOME MESSAGE*

A short welcome statement (260 characters or less including spaces) that patients will see when they log into your custom program. Ex: "Welcome to Big Smiles Dental Club. This program offers participating patients a 10% discount on our dental fees and access to a free health savings account. We value you as a patient and hope to see you soon. Give us a call to schedule an appointment."

Will you be charging any kind of fee to the patient for participating in this program?*

—Please choose an option—No. This will be free for the patient to participate.Yes. The patient will pay a fee to participate.

[group recurring clear_on_hide]
Do you currently have a way to automatically charge recurring monthly patient fees for this program?

—Please choose an option—NoYes[/group]

INCLUDE ALL DENTAL COOPERATIVE SPECIALISTS IN YOUR PROGRAM*

You can choose to include all/some/no Cooperative specialists as a referral resource in your program. Specialists offer a discount to MyHappyMouth patients.
—Please choose an option—Include all Cooperative participating specialists.Include only Cooperative specialists that I choose.Do not include any specialists.

[group SomeSpecialists clear_on_hide]
PLEASE LIST THE COOPERATIVE SPECIALISTS YOU WISH TO INCLUDE

We will include any specialists listed that are participating Cooperative members.
[/group]

Step 4) Fee Schedule and Discounts:

SELECT YOUR TYPE OF DISCOUNT OFFERED*

—Please choose an option—None.Flat percent discount off all my full-fees.Customized fee schedule and/or discounts.

[group FlatDiscountFullFees clear_on_hide]
% DISCOUNT OFF YOUR FULL-FEES*

List the percent off your full-fees you would like to offer from 1-100.

UPLOAD YOUR FULL-FEE SCHEDULE (1MB max size, xlsx/xls/csv only)

Download and fill in your full-fees: All CDT Codes-FullFees | Top 73 CDT Codes by Type-FullFees
-OR-
Export your full-fees from your practice management software: Dentrix | Eaglesoft | Open Dental
[mfile fullfees filetypes:.xlsx|.xls|.csv][/group]

[group customfeeschedule clear_on_hide]
CUSTOMIZED FEE SCHEDULE DISCOUNT

Explain the discount you will offer. You can offer varying discounts per code, discounts on specific codes, etc.

UPLOAD YOUR CUSTOM DISCOUNTED FEE SCHEDULE (1MB max size, xlsx/xls/csv only)

Download and fill in your discounted fees: All CDT Codes-Discounted Fees | Top 73 CDT Codes by Type-Discounted Fees
-OR-
Export your discounted fees from your practice management software: Dentrix | Eaglesoft | Open Dental
[mfile customfeeschedule filetypes:.xlsx|.xls|.csv][/group]

Step 5) Create Your Cards:

SELECT YOUR CARD DESIGN*

—Please choose an option—Colored BoxesGreen Wavy LinesDot Dots

UPLOAD YOUR LOGO (file types:gif|png|jpg|jpeg)

[mfile logos filetypes:gif|png|jpg|jpeg]

LANDING PAGE*

The default webpage for card access and registration is www.myhappymouth.com. Would you like to send patients directly to this site or to your own landing page prior to registering cards?
Default URL www.myhappymouth.comMy own webpage

[group preferredURL clear_on_hide]
YOUR PREFERRED URL

[/group]

CONTACT DISPLAY OPTIONS*

Default Display: Includes up to 2 locations & phone and up to 3 dentist names.Custom Contact Display: Open field

[group defaultcontact clear_on_hide]
LOCATION 1

PHONE 1

LOCATION 2

PHONE 2

DENTIST 1

DENTIST 2

DENTIST 3

[/group]

[group customcontactdisplay clear_on_hide]
CUSTOM CONTACT DISPLAY

Enter any contact display information you would like for the back of the card. This may include addresses, phone#, emails, etc. Up to 150 characters allowed including spaces.
[/group]

SUMMARY OF BENEFITS*

Up to 100 characters including spaces.

IMPORTANT INFO

Any additional critical restrictions, protections, clarifications, or information you need to add in the fine print. Up to 240 characters allowed including spaces.

TOTAL INITIAL CARDS REQUESTED*

Cards can be ordered in increments of 10. We recommend starting with 250 or less. You can reorder cards anytime on Member Services.
—Please choose an option—02050100150200250

NOTES FOR THE DENTAL COOPERATIVE

TERMS AND CONDITIONS OF PARTICIPATION
To qualify for participation with the MyHappyMouth program, participants must meet the following criteria:
• Practice must be a current member of the Dental Cooperative in good standing.
• Practice has read the associated Legal Notes and Guidelines found in Member Services that applies to their state.
• Practice has accommodated the state legal requirements for their MyHappyMouth program.
• The Practice has had the opportunity to consult a legal advisor in help creating their MyHappyMouth if they so wish. The Dental cooperative is not a legal advisor.
• The Practice recognizes any MyHappyMouth program is not dental insurance and will not represent it as dental insurance or an insurance product of any kind.
• Upon termination from the Dental Cooperative, the Practice and associated patients will no longer have access to any MyHappyMouth resources.
• Additional program details and terms may be available on Member Services and/or your Associate Agreement.

I agree to the Terms and Condition of Participation in this Agreement.

Name of Authorized Agent*

Date Agreement Signed* mm/dd/yyyy

Signature of Authorized Agent*

Once submitted, we will begin to create your MyHappyMouth program. A confirmation will be emailed to you when your program has been created.