Get Cash Pay Patients
Ilekun Health provides you cash-pay patients.

Complete this form and we start sending you cash-pay patients in your zip code at no cost to you for your first few months.

If you have questions, please contact us at hello@ilekunhealth.com.

By submitting this form you agree to our terms and conditions here: shorturl.at/cnGL4.
Do you accept dental insurance? *
How important is insurance in acquiring patients? *
not important
very important
How important is generating cash pay revenue (bypassing insurance)? *
not important
very important
Do you offer your own in-house insurance alternative? (E.g. Annual or monthly subscription) *
Are you accepting new patients? *
What procedures can you offer fixed prices for? *
Select as many as apply
Required
How soon can patients make appointments? *
Do you offer telehealth appointments? *
Contact info
Provider First name *
Legal name
Provider Last name *
Legal name
Provider Phone *
not practice number
Provider E-mail *
not practice email
Practice Name *
Practice Address *
Practice Phone *
Practice E-mail *
Preferred contact method
Anything else?
Questions and comments (E.g. challenges finding and retaining patients)
Submit
Never submit passwords through Google Forms.
This form was created inside of Ilekun Health. Report Abuse