Dental Membership Application Form

Fields marked with an asterisk (*) are required.

Name of Member(s):*
Contact Information:
Address:*
Street Address Address Line 2 City State ZIP Code
Phone:*
Email:*
Membership Information:
Membership Plan:*
Commencement Date of Plan:*
MM slash DD slash YYYY
Location Preference:*
*
- I agree to the following statement below:*
  The undersigned Associated Dentists Dental Plan Member, for himself or herself and for any child who is also a Member, hereby agrees that (i) a copy of the Dental Membership Plan document has been provided; (ii) the Member has read and understands all of the terms and conditions of the Plan; (iii) the Member understands that the Plan is not dental insurance and that fees paid for the Plan are NON-REFUNDABLE; and (iv) the Member understands that the Plan may be terminated at any time, at the end of any plan year.