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       Practice Information 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? Do you currently offer in-house patient financing? Yes No Do you currently offer outsourced patient financing? Yes No

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