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We want to support you, the same way you've supported us.
Thank you for being a trusted partner and friend to eAssist! We've had the pleasure of working with you and your clients for many years, and we're excited to announce the launch of our brand new eAssist Consultant Network. This is a brand new initiative and you are part of the FIRST consultants invited to participate.

This enrollment form will let us gather the information needed to refer our customers in need of consulting services to you. So, please complete all fields as you'd like them to appear on our website and sign the acknowledgement form at the bottom of this page. You can then email your headshot and company logo to: consultantnetwork@eAssist.me!

Then our team will get to work adding your consulting business information to our DentalBilling.com website for all of our clients and leads to refer to when in need of consulting services. Thank you! We are grateful for your continued support. If you have any questions, please contact: penny.reed@eAssist.me
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Email *
Full name *
Phone number *
Mailing address *
Company name *
Company website *
Please include a short bio about yourself/your business: *
How long have you been consulting dental practices/teams? *
Required
What are your primary consulting specialties (please choose up to 3)? *
Required
Have you ever referred your clients to eAssist? *
Required
eAssist Consultant Network; Right to Use Name & Materials For valuable consideration, I acknowledge and agree to being part of the consultant network created by eAssist Inc. and its affiliates (“eAssist”).  In connection with that designation, I grant eAssist and its assigns, licensees, and successors, the irrevocable right and license to use my image and name, as well as video or audio recordings of me and/or stories, photos, experiences, podcasts, social media posts, emails, testimonials, reviews, articles, blogs or logos I share with or provide to eAssist, in all forms and media, including composite or modified representations (collectively, the “Materials”), for all purposes, including advertising, promoting, designating or announcing my participation in such consultant network (the “eAssist Consultant Network”) (whether online, in print, via email or any other format, media or platform), and any other commercial purpose throughout the world, royalty-free and in perpetuity.  I acknowledge that the information I provide to eAssist is accurate and truthful to the best of my knowledge. I agree that I am solely responsible and liable for content, stories and experiences I share about others besides myself.  I waive the right to inspect or approve versions of the Materials, or related summaries, bios or articles prepared by eAssist, that may be used by eAssist in connection therewith.I release eAssist and eAssist’s owners, directors, officers, employees, contractors, assigns, licensees, and successors from any claims that may arise regarding the use of any Materials, including any claims of defamation, invasion of privacy, or infringement of moral rights, rights of publicity, or copyright. eAssist is permitted, although not obligated, to include my name as a credit in connection with the Materials. I waive the right to receive any payment or compensation for use of any Materials.Conducting BusinessI agree to generally promote and speak well of eAssist.  I agree to promptly notify eAssist if I hear of or have any concerns about eAssist products or services.  I agree to conduct my business in a manner that reflects favorably at all times on eAssist’s products and services, and the good name, goodwill and reputation of eAssist.  I agree not to disparage eAssist or do anything that would cast eAssist or its employees or contractors in an unfavorable light, or injure any such party’s goodwill, business reputation or relationship with other parties.  Any referral agreement, including any compensation I may be paid for referrals to eAssist, will only be valid if set forth in a separate written agreement between me and eAssist.AnnouncementsI agree not to issue any press release or other public announcement of this Acknowledgment or my participation in the eAssist Consultant Network or my relationship with eAssist without the prior written consent of eAssist.  ConfidentialityI acknowledge that all knowledge, information and data not generally known or available publicly with respect to the business, operations and marketing of eAssist and its products and services that I may learn or discover is confidential information of eAssist, and that I will not use or disclose such confidential information to any third party without the prior written consent of eAssist.Limited License for eAssist LogoIf eAssist provides me with an eAssist logo or other eAssist materials, I agree that I am only permitted to use the same for co-marketing purposes consistent with my participation in the eAssist Consultant Network described in this Consultant Acknowledgement (this “Acknowledgment”) and in the specific way that is pre-approved by eAssist in writing.  I agree that eAssist retains full ownership of all such logos and other materials.TerminationEither I or eAssist may terminate my participation in the eAssist Consultant Network upon 15 days’ written notice, provided that if I breach this Acknowledgement, eAssist may terminate my participation immediately.    eAssist is not obligated to utilize any of the rights granted in this Acknowledgement.I have read and understood this Acknowledgement and I am over the age of 18. Digital or electronic signatures are effective and will be deemed original.  This Acknowledgment expresses the complete understanding of the parties. *
BY TYPING YOUR NAME BELOW, YOU ARE AGREEING TO AND SIGNING THIS ACKNOWLEDGMENT.
Once you submit this form, please EMAIL your preferred headshot and company logo to: consultantnetwork@eAssist.me 
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