Lasting Impressions Family Dental Care

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.

Lasting Impressions Family Dental Care

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

Plan Name	Monthly	Yearly
Preventative Care 2 Exams, 2 Cleanings, 2 Fluoride treatments, 1 Set of bitewing x-rays, 1 Panoramic or full mouth x-ray (every 3 years), 1 Comprensive exam (every 3 years), 25% off of services or goods. $50 fee at time of visit. One-time fee of $200 for all new patients (includes new patient comprehensive exam).	$20.00/ mo	$240.00/ yr
Periodontal Maintenance 2 Exams, Periodontal maintenance visits (as recommended by the doctor), 2 Fluoride treatments, 1 Set of bitewings, 1 Panoramic or full mouth x-ray (every 3 years), 1 Comprehensive exam (every 3 years), 25% Off of services or goods. $75 fee at time of visit. One-time fee of $200 for all new patients (includes new patient comprehensive exam).	$20.00/ mo	$240.00/ yr

Primary Account Holder

Who will be the primary individual in charge of the account? This person will receive email reminders and billing notifications, and may or may not be enrolled in a dental plan.

First Name *

Last Name *

Email Address

Phone Number *

Address Line 1 *

Address Line 2

City *

State *

Zip *

Check this box if you would like to enroll this person in a dental plan.

Allow Text Messages.

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.

Dental Plan Registration

Lasting Impressions Family Dental Care

Preventative Care

Periodontal Maintenance

Primary Account Holder

Dental Plan Members

Members

Billing Details

Ready to submit?

Thank you!