Welcome to Rolling Hills Dental Referral Rewards!
Share a smile, be rewarded! If you'd like to refer someone, complete the following submission form for each individual you would like to refer and receive the following Smile Rewards:

$25 for referring 1 New Patient
$50 for referring 2 New Patients
$150 for Referring 3 New Patients

Referral Rewards are issued per referral household, for referrals outside the household, and honored upon the referred new patient's 1st visit within a 3-month period.

To track your referrals, just complete the form below for each referral you'd like to submit. Your reward may arrive sooner, however, please allow 90 days from the date of your referral patient's first visit to receive your gift card by mail.

For information on our Smile Ambassador B2B referral program, please send an email to care@rhdsmiles.com.

Thank you for participating!

-The Team at Rolling Hills Dental
Email address *
Where Southern Hospitality Meets High-Tech Dentistry
Your First Name *
Your Last Name *
Are you an *
Today's Date *
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Your Street Mailing Address *
Your City *
Your State *
Your Zip Code *
Your Referral's First and Last Name *
Your Referral's Phone Number *
Referral's E-Mail Address
Notes about your referral for Rolling Hills
A copy of your responses will be emailed to the address you provided.
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