Dental Discount Plan Application

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(Note: All amounts above are annual pricing and are subject to the initial one-time sign-up fee of $9.99 per application.)
** Family Plan includes up to 6 members (unmarried children only)
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Subscriber Information
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Please specify your email address.

Patient 1
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Patient 2
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Patient 3
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Patient 4
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Patient 5
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Patient 6
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Patient 7+
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Current Total
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Payment
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2 digit month: i.e. January is 01

2 or 4 digit year: i.e. 2023 is 2023 or 23

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Please bring your cash or check to any of our Signature Smiles Offices.
I understand the discounts and services provided with this plan, acknowledge all information is correct and payment for services is due day of treatment. I understand that by signing this form I give authorization to charge my credit card for the above referenced enrollment fee.
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(*) Required Fields

THIS PLAN IS NOT INSURANCE and is not intended to replace insurance. This plan is not a Qualified Health Plan under the Affordable Care Act. The plan provides discounts at certain health care providers for dental services. The range of discounts will vary depending on the type of service. The plan does not make payments directly to the providers of dental services. Plan members are obligated to pay for all health care services but will receive a discount from those health care providers who have contracted with the discount medical plan organization, in accordance with the specific pre-negotiated discounted fee schedule. This program does not guarantee the quality of the services or procedures offered by the providers. This program shall make available before purchase and upon request, a list of program providers, including their address and specialty. For further information, please contact: The Dental Discount Plan Administrator P.O. Box 10864 Houston, TX 77206; (713) 802-0011; www.mysignaturesmiles.com