2. Sign Up and download your immediate ID#

Hidden
Status
canceled by member should auto unsubscribe user from mailchimp
Hidden
Opt out of Mailchimp
- Yes
Hidden
Plan Canceled
- Yes
Hidden
Misc Member Notes
record any discounts or conversations in this field, the more information the better
Membership Type*
- Individual Plan: One Year Plus One Free Month Added! 13 Months Total ($89.95 plus one time non-refundable $10 processing fee)
- Family Plan: One Year Plus One Free Month Added! 13 Months Total ($129.95 plus one time non-refundable $10 processing fee)
Are you renewing your plan?*
- Yes
- No
Please enter your current membership ID# here. You can find this in your renewal email or on your current membership card.

If you can't find your membership ID just type in "renew" and we will do the rest.
Your Name*
First Last
Your Legal First & Last name
Email

A confirmation email along with your membership information will be sent to you at this address.
Phone*
Date of Birth*
*We do not need additional family members' birth dates. Only the primary.
Primary Member Name
First Last
The name you would like printed on your Membership Card. Or, if you are signing up for someone else, enter their name here.
List Family Members

If you selected the family plan above then enter the additional family members.
Referred by or Referral Code

If a friend, family member, or co-worker referred you make sure to give them credit!
Dentist Last Name

(Optional)
Enter Office Code

If you received a code from your dental office enter it here. Leave empty for none.
Administrative Code

(Administrative use only. Most of the time this will be left blank.)
Address*
Street Address Address Line 2 City State ZIP Code
Shipping Address
Street Address (Only required if different from address above.) Address Line 2 City State ZIP Code
Payment Method*
- Credit Card
- Check
(For check payments simply complete this form and then call us to process check by phone. You can also mail a check to: DentaCard Discount Dental Plan 781 Beta Drive Suite I Mayfield, OH 44143 Please note plans will not be active until payment is received.)
Hidden
Payment Received
- Unpaid
- Paid
Credit Card*
Card Details
Cardholder Name
Total
$0.00
Go Green | Paperless Option
- Select here if you would like to go green!
- No thank you, send me physical cards.
Would you like to help the environment and only receive emailed membership information. If checked you will not receive physical cards in the mail. (Be sure email address is entered toward the top of this form.)
Terms*
I have read the Terms and Conditions and wish to purchase the Discount Medical Plan.
Hidden
Plan Information
Hidden
Newest Membership: Programmatically pick Plan Start Date Based on either new plan or their ID number here
MM slash DD slash YYYY

If they are renewing and typed in their membership ID# above, database should look up their ID number and enter it here. If this is a new plan, today's date should be entered here.
Hidden
Newest Membership: Programmatically pick Expiration Date Based on either new plan or their ID number here
MM slash DD slash YYYY

If they are renewing and typed in their membership ID# above, database should look up their ID number and then choose 13 months from that start date and enter it here. If this is a new plan, the date 13 months from today should be entered here.
Hidden
Membership ID Number

membership ID number uniquely generated into this field
Hidden
Past Plan Information
this probably isn't needed there should already be additional entries
Hidden
Past Membershp Expire Date
Hidden
Resend Sign Up Email
change value to any option and their initial sign up email will send again after clicking update/save
Hidden
Opt out of automated reminder calls
- yes
Hidden
Stop Sending Mail (No Mailer)
- Yes

DentaCard

Discount Dental Plans Join Today!

2. Sign Up and download your immediate ID#

DentaCard Sign Up (1)

Plan Information

Past Plan Information