Get Your Referral Portal Set Up
New Referral Router — request early access
Use this form for an existing referral portal setup request. For the new Referral Router, request early access. Sample pilots are by invitation and use invented patients only.
Your Contact Details
The person submitting this application.
Principal dentist or responsible clinician
Practice Details
Your referral portal will be hosted at name.practicedomain.com. We'll configure DNS during setup.
Practice Contact Details
How referring dentists will contact you. Shown on your portal and referral communications.
Branding
Optional — you can provide these now or we'll apply them during setup.
Services You Accept Referrals For
Select all that apply.
Practice Price Book
CBCT prices are required when CBCT is selected. Consultation and custom items are optional. Everything remains editable from your tenant admin dashboard.
Consultations and other services
Add as many or as few as you need.
Staff Accounts(can be added later)
Add the people who will manage your portal.
Administrator
Full access — manage referrals, settings, and staff accounts.
Staff
Referral access only — view and process referrals.