Congratulations! You have taken the first step in bringing ALL Care Patient Financing to your practice. In order to better understand the specific needs of your practice, we ask that you complete a short survey. This Practice Profile will be delivered to you ALL Care account representative for use in creating your custom patient financing solution. Please Note: The shaded fields are required to complete your profile. Contact Information       Practice Name:   Primary Contact: Mailing Address: City /State / Zip:         Business Phone: Ext. Business FAX: E-Mail: Web Site: Contact Method: Telephone E-Mail Mail       Best Call Time:   How did you hear about us: Magazine Conference Received Fax Received Ad in the Mail Referred Internet Search Other Over 10,000 new patients each year ask us to refer them to a dentist. Enroll your practice today to gain exclusive access to patients in your area with an immediate dental need. Would you like to enroll your practice in our patient acquisition program? If yes, please check the box. Would you like to have exclusivity for patients in need of immediate dental care for your zip code? If yes, please check the box. Practice Information Average Treatment Amount $500 $1000 $1500 $2000 $2500 $3000 $3500 $4000 $4500 $5000 $5500 $6000 $6500 $7000 $7500 $8000 $8500 $9000 $9500 $10000 and up Select your dental specialty. General Dentistry Cosmetic Dentistry Endodontic Dentistry Orthodontic Dentistry Pediatric Dentistry Oral Surgery How long has your practice been in operation? How many locations does your practice maintain? How many dentists are affiliated with your practice? Approximately how many patients do you see per month?

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