Enrollment

Adults $85 per year
Family Plan $175 per year
(4 or less members at 14 years and under)
No Yearly Maximums | No Deductible
No Pre-existing Exclusions | No Claim Forms to Fill Out
No Insurance Company Denials of Coverage

Please complete this form to enroll in the Family + Dental Plan.

 

Last Name *
First Name *
Date Of Birth *
Home Address *
City/State/Zip *
Phone Number *
Email *
Supose's Last Name
Supose's First Name
Supose's Date Of Birth
Dependent(up to 14year of age)
Date Of Birth

As a patient, I wish to apply for a membership in the Friends + Family Savings Plan. I understand all services under this program must be obtained at a Family + Dental Center and further, that my payment will be due in full at the time service is rendered. This is not an insurance program.