Menu
Home
1. Find Dentists & See Savings
2. Sign Up – Immediate ID#
HSAs/Groups
How it Works
Contact Us
Upgrade to Vision and Rx Today!
Complete the form below to upgrade.
Questions? Click Here to Learn
More
or Contact Us.
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
*
ADD VISION AND RX TO YOUR INDIVIDUAL PLAN: $29
ADD VISION AND RX TO YOUR FAMILY PLAN: $39
Hidden
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
*
Hidden
Date of Birth
Month
1
2
3
4
5
6
7
8
9
10
11
12
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2039
2038
2037
2036
2035
2034
2033
2032
2031
2030
2029
2028
2027
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
*We do not need additional family members' birth dates. Only the primary.
Hidden
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.
Hidden
List Family Members
If you selected the family plan above then enter the additional family members.
Hidden
Referred by or Referral Code
If a friend, family member, or co-worker referred you make sure to give them credit!
Hidden
Dentist Last Name
(Optional)
Hidden
Enter Office Code
If you received a code from your dental office enter it here. Leave empty for none.
Hidden
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
Hidden
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 6150 Parkland Blvd Ste 250 Mayfield Heights, OH 44124 Please note plans will not be active until payment is received.)
Credit Card
American Express
Discover
MasterCard
Visa
Supported Credit Cards: American Express, Discover, MasterCard, Visa
Card Number
Month
01
02
03
04
05
06
07
08
09
10
11
12
Year
2023
2024
2025
2026
2027
2028
2029
2030
2031
2032
2033
2034
2035
2036
2037
2038
2039
2040
2041
2042
Expiration Date
Security Code
Cardholder Name
Total
$0.00
Go Green | Paperless Option
Check this box if you would like to go green!
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.)
Hidden
Go Green | Paperless Option
I'd like to help the environment, please only email me my membership information. (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 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 Start Date
Month
1
2
3
4
5
6
7
8
9
10
11
12
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2039
2038
2037
2036
2035
2034
2033
2032
2031
2030
2029
2028
2027
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
only used on initial import for members first past plan..... in the future past plans should show up as older entries so that should be fine. because email is unique identifier coupled with ID number the user on renewal should get the correct information meanwhile we should have a record of all of their plans. please ask Adam if you need a more detailed history of someone's plans.
Hidden
Past Membershp Expire Date
Month
1
2
3
4
5
6
7
8
9
10
11
12
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2039
2038
2037
2036
2035
2034
2033
2032
2031
2030
2029
2028
2027
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Hidden
Resend Sign Up Email
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
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