Practitioner Registration

Practice Information

1. Does your practice currently utilise any other third party payment plan systems?
   Yes No

   Please select all that apply:

   Denticare
   MediPay
   MiFund Loans
   Other
   
   
2. Does your practice use HICAPS?
   Yes No
3. What type of practice are you?
   General Dental
   Specialist Dental
   Please select:

   Family
   Cosmetic
   Special Interest Fields
   Other
   
   
   Please select:

   Orthodontics
   Periodontics
   Prosthodontics
   Endodontics
   Oral Surgery
   Paedodontics
   Other
   
   
4. How many dental chairs do you currently operate?
   Please select an option 1 2 3 4 5 6-8 9-10 11+
5. What is your estimated revenue for the current financial year?
   Please select an option Up to $1mil $1mil to $3mil $3mil Plus
6. Why are you interested in providing MySmilePlan payment plans to your patients?
   Please choose the 3 most relevant to you
   Increase treatment plan acceptance rates by reducing the upfront payment for the patient
   Reduce overhead costs in time invested chasing outstanding accounts
   Improve your business cash flow and create more cash flow predictability
   Assist you in marketing your practice with a point of difference
   Cover all laboratory and business expenses for the case at start of treatment
   Allow more patients in your area to seek crucial dental care which they would otherwise delay/avoid
   Cannot afford to wait months/years for payments to be made to you as with other third party payment plan systems