Form

Smart Smile Club Enrollment Form

Please complete the applicable fields for yourself and any additional family membership you wish to enroll.

First Name

Last Name

Date Of Birth

Address

City

Zip Code

Phone

Email

First Name

Last Name

Date Of Birth

Phone

Email

First Name

Last Name

Date Of Birth

Phone

Email

First Name

Last Name

Date Of Birth

Phone

Email

Payment

Membership enrollment fees must be paid in full prior to any dental care procedures.

Total Membership Fees

Once your form is received and processed, you will receive a text or email with a link to pay online. If you prefer to pay over the phone, please call (309) 454-7337 during business hours.

Patient/Legal Guardian Signature

Date