About
Team
Leadership Team
Dental Advisory Board
Business Development
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Affiliation
Services
Geographic Focus
Contact
BECOME A PARTNER
Complete the form below to explore a potential partnership.
Your Information
FIRST NAME
LAST NAME
DENTAL SCHOOL
DENTAL SCHOOL GRADUATION YEAR
EMAIL
PHONE
PHONE TYPE
---
Cell
Office
Home
ADDRESS
CITY
STATE
---
Texas
Utah
ZIP CODE
PREFERRED METHOD OF CONTACT
---
Email
Phone
No Preference
About Your Practice
TYPE OF PRACTICE
General
Orthodontics
Endodontics
Pediatrics
Periodontics
Prosthodontics
Oral and Maxillofacial Surgery
Other
NUMBER OF LOCATIONS
---
0
1
2
3 or more
PRACTICE NAME
OWN OR LEASE
---
Own
Lease
Other...
SQUARE FEET
NUMBER OF OPERATORIES
0
1-4
5-9
10 or more
ADDRESS
CITY
STATE
---
Texas
Utah
ZIP CODE
OFFICE PHONE
Payor Mix
PPO %
FFS %
MEDICAID %
HMO %
ANNUAL REVENUE
Personal Plans and Goals
HOW LONG DO YOU PLAN TO CONTINUE WORKING AT YOUR PRACTICE?
---
less than 1 year
1 - 3 years
3 - 5 years
5 or more years
WHAT ARE YOU LOOKING FOR FROM AN AFFILIATION?
ANY ADDITIONAL QUESTIONS OR COMMENTS FOR US?
HOW DID YOU HEAR ABOUT US?
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Internet Search
Email
Direct Mail
Tradeshow Conference
Star Dental Partners Referral
Other
Over the next few weeks, I would like to hear directly from a dentist who has already made the decision to affiliate their practice with you.
