Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Are you an existing patient?
*
Please Select
Yes
No
Preferred Contact Method
Please Select
Phone
Email
Please verify that you are human
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Select Your Dental Membership Plan(s)
You can select multiple plans or quantities for additional members of your family. If you a purchasing multiple plans, please use the space below this form to include the names of all members being added to the plan.
My Products
*
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( X )
ID VALUE MEMBERSHIP PLAN
Adults $78/ Month - Billed Annually
$
936.00
Quantity
1
2
3
4
5
6
7
8
9
10
ID PLATINUM MEMBERSHIP PLAN
Adults $99/ Month - Billed Annually
$
1,188.00
Quantity
1
2
3
4
5
6
7
8
9
10
ID PERIO MEMBERSHIP PLAN
Adults $149 / Month - Billed Annually
$
1,788.00
Quantity
1
2
3
4
5
6
7
8
9
10
Credit Card Details
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
Billing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
If you are buying plans for multiple members, please enter each name below
Terms & Conditions
*
I agree to the terms and conditions for the dental membership plan, and I authorize Integrated Dental to bill my card for the amount specified above
Where did you hear about us?
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