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DentaCard Sign Up
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Status
Active
Expired
Future
Canceled
Payment Pending
canceled by member should auto unsubscribe user from mailchimp
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Opt out of Mailchimp
Yes
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Plan Canceled
Yes
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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
*
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*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
AL
AK
AS
AZ
AR
CA
CO
CT
DE
DC
FL
GA
GU
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
MP
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
VI
VA
WV
WI
WY
AA
AE
AP
State
ZIP Code
Shipping Address
Street Address (Only required if different from address above.)
Address Line 2
City
AL
AK
AS
AZ
AR
CA
CO
CT
DE
DC
FL
GA
GU
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
MP
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
VI
VA
WV
WI
WY
AA
AE
AP
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.)
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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.
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Plan Information
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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.
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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.
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Membership ID Number
membership ID number uniquely generated into this field
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Past Plan Information
this probably isn't needed there should already be additional entries
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Past Membershp Expire Date
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change value to any option and their initial sign up email will send again after clicking update/save
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Opt out of automated reminder calls
yes
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Stop Sending Mail (No Mailer)
Yes