Form

Dental Membership Application

First Name

Last Name

Date Of Birth

Address

City

Zip Code

Phone

Dental Membership Plans

*Family Plan includes up to 6 members of the same household (unmarried children under 25 years old) Additional family members at $149 each

LIST COVERED DEPENDENTS:

Date Of Birth

Total Payment Amount

Credit Card #

Expiration Date

CVV

I understand the discounts and services provided with this plan and acknowledge all information I have provided is correct. I know that in order to receive the 15% discount, payment for services is due the day of treatment. I understand that by signing this form I give authorization to charge my credit card for the above referenced enrollment fee. The membership fee is non-refundable.

Patient/Legal Guardian Signature

Date

THIS PLAN IS NOT INSURANCE and is not intended to replace insurance. This plan is not a Qualified Health Plan under the Affordable Care Act. The plan provides discounts at Intermountain Smiles for services. Plan members are obligated to pay for all health care services and will receive a discount in accordance with the specific pre-negotiated discounted fee schedule.