New User Intake Form

1
Legal Business Name* This field is required.
2
DBA if different
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Primary Contact Name * This field is required.
First Name
Last Name
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Business Address* This field is required.
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
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District of Columbia
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New York
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Ohio
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Oregon
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South Carolina
South Dakota
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Texas
Utah
Vermont
Virginia
Washington
West Virginia
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State
Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
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Cook Islands
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Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
5
Business Phone Number* This field is required.
Please enter a valid phone number.
6
Business Email* This field is required.
example@example.com
7
Website URL* This field is required.
8
Contact Information* This field is required.For main point of contact
First Name
Last Name
Job Title
Please enter your contact email
Direct Phone Number
9
Business Phone Provider* This field is required.
10
Routing Rules* This field is required.
Contact number to transfer calls to?
Contact Name/Group
Notification Email
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Any Business Info to Train * This field is required.Pricing, Hours of operation, procedures, doctors, etc.
Details that are unique or specific to your office.
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Info * This field is required.
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IMPORTANT: After the 60-day trial, this Agreement automatically renews monthly unless canceled before expiration. Billing will begin automatically using the payment method on file.* This field is required.
15
Signature* This field is required.
16
Select Subscription* This field is required.For Trial, Please Select Basic Plan
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Basic Plan
≈ $2.19/hour based on a 40-hour work week 24/7 AI receptionist coverage handling inbound calls and texts. We capture every lead, send detailed call summaries, and forward all information directly to your office email — so you never miss a patient again. Compare: A $20/hour receptionist costs approximately $3,200/month before payroll taxes and benefits. Includes: • 24/7 call answering • SMS/text handling • Instant email summaries • Lead capture & forwarding • After-hours coverage
Free for the first 60 days then, $350.00 for each month
SUBSCRIBE
Essential Plan
≈ $3.75/hour based on a 40-hour work week Everything in Basic — plus full social media and ad response management. We respond instantly to Facebook, Instagram, website chat, and ad inquiries and follow up with outbound calls to convert leads into booked appointments. Compare: Traditional front desk + marketing support can exceed $4,000–$5,000/month in payroll costs. Includes everything in Basic, plus: • Social media DM response • Website chat response • Ad lead response • Outbound follow-up calls • Lead conversion support
$600.00 for each month
SUBSCRIBE
Premium Plan
≈ $9.38/hour based on a 40-hour work week A fully integrated AI front desk connected directly to your practice management system. Real-time scheduling, insurance verification, and patient record updates — without adding payroll. Compare: A trained front desk + insurance coordinator often exceeds $6,000–$8,000/month fully loaded. Includes everything in Essential, plus: • PMS integration (Dentrix, Open Dental, Eaglesoft, etc.) • Real-time patient scheduling • Insurance verification • Patient record updates • Calendar sync
$1,500.00 for each month
SUBSCRIBE
Credit Card
First Name
Last Name
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