Become a Dental Partner | Dental Foundation of Grace

90% of all proceeds donated go to help those in need.

Give the Gift of Grace

Please read through the requirements before you fill out the form. You will be contacted by someone within the organization within 48 hours.

To become a partner with the Dental Foundation of Grace you must meet the following requirements:

Your practice must be licensed by the state you operate in
You and your practice must be in good standing with the surrounding community
You must have no pending legal actions against you for the last three years
Your practice must currently offer some type of payment plan for those in need
Does your practice have numbered accounts for patients for protection under HIPAA and if not would your staff be open to having HIPAA release form signed by patients?

Name*
Prefix First Last Suffix
Email*
Phone*
What is the best way to contact you:*
Location*
What is the best time to contact you:*

: HH

MM
Why are you interested in partnering with us?*
To the best of my knowledge, I meet all of the requirements to become a partner with DFOG*
- Yes, I do
- Not at this time (but I would still like to talk to someone)
Please Explain:*

Take Action

3921 Vista Greens Drive
Fort Worth, Texas, 76244
USA

817-228-6714
info@dentalfoundationofgrace.org

90% of all proceeds donated go to help those in need.