Pro Pledge Form | Dental Society

Practice:

Specialty:

Address:

Street AddressStreet Address Line 2CityState / Province / RegionPostal / Zip Code

Phone:

Area Code

Phone Number

Fax:

Area Code

Phone Number

E-mail:

Website:

Is your practice on Social Media?:

Facebook

Twitter

YES! Our practice will volunteer with Physicians Reach Out. Here’s our pledge:

We will accept the number of Physicians Reach Out referrals indicated below.

Please complete this form and fax to 704-943-3747. If you have any questions, please contact Dina Patel at 704-248-3739 or dpatel@CareRingNC.org

Name of Practice Manager/Administrator or Lead Dentist

Dentist(s)/Provider Name(s):

Each Dentist will see this number of patients per year for services.

Word Verification:

601 E. 5^th Street, Suite 140 ♦ Charlotte, NC 28202 ♦ (704) 375-0172 ♦ (704) 943-3747 fax ♦ www.CareRingNC.org