Update Your Program

Update your existing custom patient program.

Submit the request form below to update any of the following for your MyHappyMouth program:

Update the fee schedule or discounts for my program.
Request new printed cards.
Edit details for my program.
Edit details on my cards.
Send me my current database of registered patients and visits logged.
Other

Once your request is submitted, we will make the changes and then contact you.

UPDATE YOUR MYHAPPYMOUTH PROGRAM

*required

Practice and Program Information:

PRACTICE NAME*

NAME OF PRIMARY DENTIST*

NAME OF EMPLOYEE RESPONSIBLE FOR YOUR CUSTOM PROGRAM*

EMAIL OF EMPLOYEE RESPONSIBLE FOR YOUR CUSTOM PROGRAM*

COOPERATIVE ACCOUNT# (Found on Invoice. Optional)

GROUP ID#* (Group ID# for the program you need help with. This ID is found on your printed cards.)

Your Request:

HOW CAN WE HELP YOU?*
Update the fee schedule or discounts for my program.Request new printed cards.Edit details for my program.Edit details on my cards.Send me my current database of registered patients and visits logged.Other

Fee Schedule and Discounts:

SELECT THE TYPE OF DISCOUNT YOU WANT TO OFFER FOR YOUR PROGRAM*

% DISCOUNT OFF YOUR FULL-FEES*
List the percent off your full-fees you would like to offer from 1-100.

UPLOAD YOUR FULL-FEE SCHEDULE (1MB max size, xlsx/xls/csv only)
Download and fill in your full-fees: All CDT Codes-FullFees | Top 73 CDT Codes by Type-FullFees
-OR-
Export your full-fees from your practice management software: Dentrix | Eaglesoft | Open Dental

CUSTOMIZED FEE SCHEDULE DISCOUNT
Explain the discount you will offer. You can offer varying discounts per code, discounts on specific codes, etc.

UPLOAD YOUR CUSTOM DISCOUNTED FEE SCHEDULE (1MB max size, xlsx/xls/csv only)
Download and fill in your discounted fees: All CDT Codes-Discounted Fees | Top 73 CDT Codes by Type-Discounted Fees
-OR-
Export your discounted fees from your practice management software: Dentrix | Eaglesoft | Open Dental

Request New Printed Cards:

I WOULD LIKE TO:*
Order more of the same cards I have.Choose a different card design.

SHIPPING ADDRESS FOR YOUR NEW CARDS:*
ADDRESS*

SUITE

CITY*

STATE*

ZIP*

TOTAL CARDS REQUESTED*
Cards can be ordered in increments of 10. We recommend starting with 250 or less. You can reorder cards anytime on Member Services.

SELECT YOUR NEW CARD DESIGN

Edit My Program Details:

CHANGE YOUR PROGRAM NAME
Ex: Dr Smith Dental Club, Big Smiles Senior Plan, etc.

CHANGE YOUR WELCOME MESSAGE
A short welcome statement (260 characters or less including spaces) that patients will see when they log into your custom program. Ex: "Welcome to Big Smiles Dental Club. This program offers participating patients a 10% discount on our dental fees and access to a free health savings account. We value you as a patient and hope to see you soon. Give us a call to schedule an appointment."

UPLOAD A NEW LOGO (file types:gif|png|jpg|jpeg)

INCLUDE ALL DENTAL COOPERATIVE SPECIALISTS IN YOUR PROGRAM
You can choose to include all/some/no Cooperative specialists as a referral resource in your program. Specialists offer a discount to MyHappyMouth patients.

PLEASE LIST THE COOPERATIVE SPECIALISTS YOU WISH TO INCLUDE
We will include any specialists listed that are participating Cooperative members.

Edit Details on My Cards:

CHANGE YOUR PROGRAM NAME
Ex: Dr Smith Dental Club, Big Smiles Senior Plan, etc.

UPLOAD A NEW LOGO (file types:gif|png|jpg|jpeg)

LANDING PAGE
The default webpage for card access and registration is www.myhappymouth.com. Would you like to send patients directly to this site or to your own landing page prior to registering cards?
Default URL www.myhappymouth.comMy own webpage

YOUR PREFERRED URL

CONTACT DISPLAY OPTIONS
Default Display: Includes up to 2 locations & phone and up to 3 dentist names.Custom Contact Display: Open field

LOCATION 1

PHONE 1

LOCATION 2

PHONE 2

DENTIST 1

DENTIST 2

DENTIST 3

CUSTOM CONTACT DISPLAY
Enter any contact display information you would like for the back of the card. This may include addresses, phone#, emails, etc. Up to 150 characters allowed including spaces.

SUMMARY OF BENEFITS
Up to 100 characters including spaces.

IMPORTANT INFO
Any additional critical restrictions, protections, clarifications, or information you need to add in the fine print. Up to 240 characters allowed including spaces.

SELECT A NEW CARD DESIGN