New York Dental Network, LLC

Dentist-Refer-Member Referral Form

Thank you for taking time out to refer a member or group to us. The following form is to be used by NYDN Dentists who would like to refer new members or new groups to NYDN. If you are a Member and would like to refer another member or group to us, please use the member-refer-member form.

Please fill out all the information in the form below and click "Submit". New York Dental Network, LLC takes all referrals seriously and we will follow up your submission by contacting the prospective member or group you have referred to us. If you would like to refer more than one Individual Member or Group to NYDN, please fill out a separate form for each Member or for each Group.

Your Name:
Your Email Address:
Your Contact Phone Number:
Are you currently a participating NYDN dentist?	Yes No
Would you like to refer an Individual Member or a Group?	Member Group
If you are referring a Group, what is the name of the Group?
Name of Primary Contact Person (Member Name or Group Contact):
Phone Number of Primary Contact Person:
Email Address of Primary Contact Person:
If you are referring a Group, approximately how many people are part of the Group?
Have you told this Member or Group that you are referring them to NYDN?	Yes No
How do you know the Member or Group you would like to refer:
Comments: