Welcome to Rolling Hills Dental Referral Rewards!
If you're currently a Rolling Hills Patient and would 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 answer
Your Last Name *
Your answer
Are you an *
Today's Date *
MM
/
DD
/
YYYY
Your Street Mailing Address *
Your answer
Your City *
Your answer
Your State *
Your answer
Your Zip Code *
Your answer
Your Referral's First and Last Name *
Your answer
Your Referral's Phone Number *
Your answer
Referral's E-Mail Address
Your answer
Notes about your referral for Rolling Hills
Your answer
A copy of your responses will be emailed to the address you provided.
Submit
Never submit passwords through Google Forms.
reCAPTCHA
PrivacyTerms
This form was created inside of Lindahl Smiles. Report Abuse - Terms of Service
Google Forms