Delta Dental of New Mexico Customized Shopping Site Intake Form

Delta Dental of New Mexico

Customized Shopping Site Intake Form

Please fill out the form below to begin the set up of your customized shopping site.

Agent Full Name*

Agency Full Name*

If no agency, please enter N/A

Agent NPN*

Agency Website Address

Commissions Email Address*

This is the email where commission statements will be sent.

Sales Notification Email Address*

This is the email where notification of each new sale will be sent.

Enter N/A if you do not want to receive notifications.

Preferred URL Name*

This will be your customized URL extension for your individual shopping site.

Select

Site URL Name

Please note: only include your URL extension desired (ie: www.mysmilecoverage.com/__________)

Unique Logo*

Would you like your company logo or picture displayed on your personal site?

Yes

Upload Logo

If you would like your customized logo for the shopping site, please upload that logo here in a .jpg format only.

Drag and drop files here or

Shopping Site Colors*

Are primary & secondary color preferred for your site?

Yes

Do you have a VSP broker link you would like to added to your site?*

Your VSP broker link can be added to your dental sales site to ensure you receive commission if a customer added vision from your personal site.

Select or enter value

List Complete VSP URL

Hex Codes

Please type color hex codes below.

Send me a copy of my responses