Dental Membership Program – Registration

Last Name*
First Name*
MI*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Email*
Home/Cell Phone Number(s)*
Member DOB*
Eligible Dependent 1 - Name
Eligible Dependent 1 - Birth Date
Eligible Dependent 1 - Relationship
Eligible Dependent 2 - Name
Eligible Dependent 2 - Birth Date
Eligible Dependent 2 - Relationship
Eligible Dependent 3 - Name
Eligible Dependent 3 - Birth Date
Eligible Dependent 3 - Relationship
Office Location*
- Rochelle Family Dental
- Freeport Dental
- Forreston Dental
- Riverside (Savanna) Dental
- Autumn Dental (Mokena)
- Oregon IL Dental
- Charge Card. We accept MasterCard/Visa/Discover/AmEx.
Card #*
Exp. Date*
CVC#*
*
- I understand the benefits, limitations, exclusions and requirements of the Plan and I agree to the following: I will remain in the plan and pay membership fees for 12 months. Where permitted by law, payment of less than 12 months’ membership fees may result in my being charged usual and customary fees for all services (including those already provided) and my being charged remaining months’ fees in lump sum. Fees for dental services are due in FULL to the dentist as services are rendered; at or prior to appointment. Fees for prosthodontic and cast restoration services are due to the dentist in FULL at the preparation/impression visit. Failure to comply may result in my being charged usual and customary fees for such services. I agree to pay any and all costs in collecting all charges, includin g but not limited to attorney fees and court costs. Membership must be continuous. Missing monthly payments must be made up for interrupted membership. Processing fees are not refundable.
Signature*
Date