Admin Portal

Affiliate Program

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Thank you for your interest in becoming an Affiliate with Dentaperx! By partnering with Dentaperx, you are partnering with a revolutionary program that will change the way Dental healthcare is viewed and perceived. Choosing to be an affiliate for Dentaperx shows the visionary mindset you have and we are please to consider you for the program!

Please read the terms and conditions and fill out the form below to be considered.

Affiliate Program Terms & Conditions.

Once your application is received, our team will review and if you are approved we will send you the Affiliate Agreement.

Affiliate Intake Questionnaire

Affiliate Intake
Name
Name
First Name
Last Name
Affiliate Type (please select at least one)
Please select the current social media platforms you are active on.
Are you involved in any HIPAA-regulated activities?
Do you agree NOT to collect of share PHI (Protected Health Information)?
Do you agree to follow Dentaperx Affiliate Terms and Conditions?
Do you understand that Dentaperx points and rewards are NOT insurance and do NOT replace dental benefits?
Do you agree NOT to misrepresent Dentaperx as an Insurance provider, Dental Financing company or a Government program?
Preferred Payment Method (Once approved, you will be required to provide a W-9/ Tax ID/ EIN)
Do you have any financial relationships that may influence referral decisions?
Have you participated in affiliate programs before?
I certify all information provided is accurate.