Dental Plan Registration

Begin your dental plan registration by filling out the form below.

Once completed, you will finish your registration at the office where someone will help you choose the plan right for you, and your billing will start.

Kirtley & Stuckwisch Dental

You will choose one of these dental plans when you finish your registration in the office.

Plan Name Monthly Yearly

Adult Membership Plan

2 Cleanings, 2 Routine Exams, Routine Annual x-rays as prescribed, 2 Fluoride applications, 1 Emergency visit (includes exam and x-ray); 15% off additional treatment; 15% off Clear Aligners; Perio exam every year; Discounts from our referral partners: 15% off at Strull & Strull Oral Surgery; 10% off at Columbus Endodontics; 10% off at Seymour Orthodontics for comprehensive treatment. 		$31.00/ mo $372.00/ yr

Child Membership Plan

2 Cleanings, 2 Routine Exams, Routine Annual x-rays as prescribed, 2 Fluoride applications, 1 Emergency visit (includes exam and x-ray); 15% off additional treatment; 15% off Clear Aligners; Perio exam every year; Discounts from our referral partners: 15% off at Strull & Strull Oral Surgery; 10% off at Columbus Endodontics; 10% off at Seymour Orthodontics for comprehensive treatment. 		$27.00/ mo $324.00/ yr

Perio Maintenance - 4 Visit

4 Periodontal Maintenance Cleanings, 2 Routine Exams, Routine Annual x-rays as prescribed, 4 Fluoride applications, 1 Emergency visit (includes exam and x-ray); 15% off additional treatment; 15% off Clear Aligners; Oral Cancer screening at every visit, Perio exam every year; Discounts from our referral partners: 15% off at Strull & Strull Oral Surgery; 10% off at Columbus Endodontics; 10% off at Seymour Orthodontics for comprehensive treatment. 		$61.00/ mo $732.00/ yr

Perio Maintenance - 3 Visit

3 Periodontal Maintenance Cleanings, 2 Routine Exams, Routine Annual x-rays as prescribed, 3 Fluoride applications, 1 Emergency visit (includes exam and x-ray); 15% off additional treatment; 15% off Clear Aligners; Oral Cancer screening at every visit, Perio exam every year; Discounts from our referral partners: 15% off at Strull & Strull Oral Surgery; 10% off at Columbus Endodontics; 10% off at Seymour Orthodontics for comprehensive treatment. 		$50.00/ mo $600.00/ yr

Perio ALT 2 Visit Membership

*For Members who alternate with their periodontist: 2 Periodontal Maintenance Cleanings, 2 Routine Exams, Routine Annual x-rays as prescribed, 2 Fluoride applications, 1 Emergency visit (includes exam and x-ray); 15% off additional treatment; 15% off Clear Aligners; Perio exam every year; Discounts from our referral partners: 15% off at Strull & Strull Oral Surgery; 10% off at Columbus Endodontics; 10% off at Seymour Orthodontics for comprehensive treatment. 		$39.00/ mo $468.00/ yr

Dental Plan Members

Who is signing up for a dental plan? We only need basic information for now; you will choose a plan for each member and begin your billing when you visit our office.

Members

First Name * Last Name * Date of Birth *

Billing Details

Once your registration is complete and your plan is approved, how would you like to be billed?

Note: This card WILL NOT be charged until you visit the office to select a dental plan and finalize your registration. We collect this information now to speed things up during your first appointment!

Credit Card Information

This card will be used for all members associated to this responsible party.

Card Number
Please enter a valid Credit Card number
Expiration (mm yy) Example: 06 27

Ready to submit?

Please Correct all errors marked in red in your registration information and submit again

When you’re finished, click the button below to submit your information. You will not be billed until you choose a plan and finalize your registration at our office.