SacSmiles Dental Insurance Enrollment Form
Welcome! Fill in the details below and we will reach out to confirm your enrollment in one of our in-house dental insurance plans!
Which Plan Would You Like to Enroll In? We will reach out to confirm and obtain payment info.
Basic Plan - $650/Year
Perio Plan - $900/Year
Kids Plan - $550/Year
Please note that any information submitted through this form will be forwarded to our office by e-mail and not via a secure messaging system. This form should not be used to transmit private health information, and we disclaim all warranties with respect to the privacy and confidentiality of any information submitted through this form
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