Enrollment Form: TIP

TIP Sign-Up:

1. Practice Name *This question is required.

2. CareCredit Representative *This question is required.

3. Name of Doctor on CareCredit Account *This question is required.

4. Practice Type *This question is required.

5. Mystery Shop Focus *This question is required.

5. Practice Phone Number to be Shopped *This question is required.

6. Your Website *This question is required.

7. Anything to tell us about your advertising, competitors, or anything else?

By entering my name, I authorize Interaction Metrics and its affiliates to call my practice and record these calls.

8. Your Full Name *This question is required.

9. Your Email Address *This question is required. This question requires a valid email address.

10. Today's Date (MM/DD/YYYY) *This question is required.