Senior Dental Plan 1 Select Individual or Couple2 Personal Information3 Terms and Conditions Senior Dental PlanPrimary Account Holder* First Last Who are you purchasing this plan for?MeSomeone ElseRecipient NameRecipient Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code DOB* MM DD YYYY Select Individual or Family*IndividualFamilyWhere did you hear about SDP?*Total $0.00 Enrolled Family MembersSpouse First Last DOBMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 Smilebuilderz Select & Senior Dental Programs Terms & Conditions Dr. Anthony Skiadas and associates at Smilebuilderz , Urgent Dental Care and Immerzion have made it possible for any individual or family to obtain the highest quality dentistry at affordable fee’s. This program is NOT INSURANCE. This membership cannot be combined with any other dental insurance benefits. This plan is a reduced fee discount plan and only applies to the services offered at Smilebuilderz, Urgent Dental Care and Immerzion. All Dental Plans have a 30 day processing period from the day of purchase until the member is eligible to receive the discounted fee’s for treatment. The programs have no yearly maximum, no restrictions as to what type of service is covered and needs no authorization for permission to provide dental services. The annual fee will guarantee you the discounted fee schedule associated with the smilebuilderz dental plan that you have chosen. Procedures and services available at smilebuilderz are outlined in the dental plan brochure. Your membership will be valid for one year upon full payment of the enrollment fee. Your membership is subject to termination for nonpayment of membership fee and/or nonpayment of costs associated with treatment/procedures. All services are to be paid in full at the completion of the procedure with the exception of Orthodontics (Braces). All orthodontic treatment must be paid in full at the time of banding to receive the discount. EXCLUSIONS – Completed procedures will not be included in the membership discount. Procedures/treatment already in progress will not be included in the membership discount. Procedures that are included in the program: Diagnostic Preventive Dental Restorative Services Cosmetic Restorative Dentistry Endodontic Periodontic Oral Surgery Orthodontics – All orthodontic procedures must be paid in full at time of banding Miscellaneous Dental Services (Teeth Whitening – Night, Sport and Occlusal Guards) Please refer to the Smilebuilderz Dental Plan brochure for discount percentages on procedures and free services associated with the plan of your choosing. We have a 30 day cancellation policy with a money back guarantee if no services have been rendered within that time. I have read and agree to the above terms and conditions. Printable Terms and ConditionsTerms and Conditions* I have read and agree to the terms and conditions. Phone*Email* Billing Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Credit Card* American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20172018201920202021202220232024202520262027202820292030203120322033203420352036 Expiration Date Security Code Cardholder Name Please only push the submit button one time. Thank you.
