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.

Next Step Dental

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

Plan Name Monthly Yearly

Child Membership Plan

2 Regular exams, 2 Cleanings, 2 Fluoride treatments, 1 Set of bitewing x-rays, 1 Panoramic x-ray (when indicated), 1 Emergency visit (includes exam and one x-ray), and 15% OFF additional treatment. 		$25.00/ mo $300.00/ yr

Perio Membership Plan - 4 Visit

4 Periodontal maintenance cleanings, 2 Exams, 2 Fluoride treatments, 1 Set of bitewing x-rays, 1 Panoramic x-ray (when indicated), 1 Emergency visit (includes exam and one x-ray), Oral cancer screenings, and 15% OFF additional treatment. 		$51.00/ mo $612.00/ yr

Adult Membership Plan

2 Cleanings, 2 Exams, 2 Fluoride treatments, 1 Set of bitewing x-rays, 1 Panoramic x-ray (when indicated), 1 Emergecny visit (includes exam and one x-ray), Oral cancer screenings, and 15% OFF additional treatment. 		$30.00/ mo $360.00/ yr

Perio Membership Plan - 3 Visit

3 Periodontal maintenance cleanings, 2 Exams, 2 Fluoride treatments, 1 Set of bitewing x-rays, 1 Panoramic x-ray (when indicated), 1 Emergecny visit (includes exam and one x-ray), Oral cancer screenings, and 15% OFF additional treatment. 		$42.00/ mo $504.00/ 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.