Create a Support case

To create a Support case, please complete the required fields on the form below and then click send.

Please be as specific as possible with your support request. By initially providing more detail our team can more efficiently look into your request .

Your preferred contact selection will be used whenever possible. However, depending on the nature of your submission, support may contact you with either method.




MEDENT Account #*

Practice Name*

Your Name*

Title:

Preferred contact method*

Preferred phone # for call back*

- -

Practice phone #

- -


E-Mail Address*


Area of System *

Subject*

Description of Support Inquiry*


Provider: *

Providers Affected:

Patients Affected: *

How many Patients?

Patient Examples (up to 5): (optional)

File Attachment: (optional - 8MB max)
(.png,.jpg,.jpeg,.pdf,.xls,.xlsx,.doc,.docx,.tiff,.tif)