Dental Provider Questionnaire

Dental Departures is the #1 site to find a global dentist. When our customers visit a global dentist they save 70% on their dental care. Dental Departures partners with 1300+ dentists in 28 different countries around the globe.

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Why become a Dental Departures partner?

Dental Departures is #1
We are the #1 place for patients to find global dentists
NO set-up fees
No set-up, monthly, annual or premium listing fees
Pay for completed appointments
Pay Dental Departures a commission
Patients pay you
Patients pay your clinic and then your clinic pays Dental Departures a commision afterwards
FREE photos of your clinic
Dental Departures takes high resolution photos of your clinic ^{*only specific countries}
24/7 customer care support
Customer care for your patients and your clinic
Appointments are FREE
Customers do not pay to schedule an appointment
Multi-currency pricing
Your dental clinic pricing will be priced in 8 different currencies
Real reviews from real patients
Dental Departures makes it easy to gather reviews from your patients and allows your clinic to respond to them
FREE virtual tour of your clinic
Dental Departures takes virtual tours of every room in your clinic ^{*only specific countries}

Thank you for your interest in becoming a dental provider with Dental Departures. We will use the information in this questionnaire in part to determine if we select your dental clinic to partner with and refer patients to. Please answer the following questions as completely and accurately as possible.

You will receive a reply back from Dental Departures within 7 business days. If you have any questions please e-mail: questionnaire@dentaldepartures.com or call 1 888 504-2671

Contact Information First Name Last Name Title Address 1 Address 2 City Province / State Country

Postal Code / Zip code E-mail Address Phone Number

Dental Clinic Information

Same as contact

Name Address 1 Address 2 City Province / State Country

Postal Code / Zip Code Website E-mail Address Phone Number

Other Clinic Information

Year Established

What international accreditation does your dental clinic qualify for

American Dental Association	ISO 9002
European Society of Esthetic Dentistry	International Congress of Oral Implantologists
ISO 9001:2008	Joint Commission International
American Lingual Orthodontics Association	Highest quality in medicine certificate
Other

Dentists What is your primary dental license governing body? What is your dental license registration number with your governing body? What guarantees do you provide for your dental procedures (i.e. 2 year product/services, 5 year products/services)?

Does your entire clinic speak English fluently?

Yes No

If not, what other languages are spoken fluently? What malpractice insurance do you carry? What are your dental clinic’s sterilization techniques?

Legal

Has any dentist in your clinic been charged with malpractice?

Yes No

Please explain

Has anyone in your clinic been convicted of a crime?

Yes No

Please explain

Has any dentist on your staff had their license revoked?

Yes No

Please explain

Have any complaints been filed against your dental clinic with your regional dental association?

Yes No

Please explain

Submit Questionnaire

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Save up to 70% compared to treatment at home

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