Share a Smile Referral Program

Refer a Friend or Family Member to Hudec Dental!

As a thank you, you’ll receive a digital $25 gift card.

Some restrictions apply. Form must be completed.

Not valid on HMO and Medicaid plans.

How it Works

For Referring Patients:

Once you’ve scanned the QR Code, complete the short form below, and once the New Patient schedules an appointment we will send you a digital giftcard via email!

For New Patients:

Once you’ve scanned the QR Code, complete this short form below, and continue on to schedule your appointment. We can’t wait to see you!

Complete the Following Information:

I am a:(Required)

Referring Patient (referring someone)

New Patient (being referred)

Your Information (Referring Patient)

Your Name(Required)

First Last

Email(Required)

Phone(Required)

Name of Patient You are Referring(Required)

First Last

Phone Number of Person You are Referring(Required)

Your Information (New Patient)

Name(Required)

First Last

Email(Required)

Phone(Required)

Opt-In to Text Message Communication

Opt-In

By checking this box, I agree to receive conversational and customer care related text messages (SMS) from Hudec Dental. Message frequency may vary. Message and data rates may apply. You can reply STOP to opt-out at any time. For assistance, reply HELP. Check the Terms in our Privacy Policy and Terms of Use for SMS.

Preferred Location

What is the Name of the Person Who Referred You?