Gentle Care Membership Enrolment | Gentle Creek Dental

Gentle Creek Dental Membership Enrollment

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Step 1 of 3

Responsible Party Information

Please enter the name, mobile and address for the responsible party that will be billed for this account.

Name*

Email*

Phone*

Address*

How many members total will be on your plan?*

Please enter a number from 1 to 8.

Add Members

Please list the name, birthday and desired program for each member (including yourself, if you wish to be a member).

Member 1

Name*

Date of Birth*

Dental Membership Type*

Select your membership type. Adult $35/mo (ages 13+), Child $25/mo (ages 12 & under), or Perio $50/mo (for patients with periodontal disease). All plans include a one-time $99 activation fee.

Member 2

Name*

Date of Birth*

Dental Membership Type*

Select your membership type. Adult $35/mo (ages 13+), Child $25/mo (ages 12 & under), or Perio $50/mo (for patients with periodontal disease). All plans include a one-time $99 activation fee.

Member 3

Name*

Date of Birth*

Dental Membership Type*

Select your membership type. Adult $35/mo (ages 13+), Child $25/mo (ages 12 & under), or Perio $50/mo (for patients with periodontal disease). All plans include a one-time $99 activation fee.

Member 4

Name*

Date of Birth*

Dental Membership Type*

Select your membership type. Adult $35/mo (ages 13+), Child $25/mo (ages 12 & under), or Perio $50/mo (for patients with periodontal disease). All plans include a one-time $99 activation fee.

Member 5

Name*

Date of Birth*

Dental Membership Type*

Select your membership type. Adult $35/mo (ages 13+), Child $25/mo (ages 12 & under), or Perio $50/mo (for patients with periodontal disease). All plans include a one-time $99 activation fee.

Member 6

Name*

Date of Birth*

Dental Membership Type*

Select your membership type. Adult $35/mo (ages 13+), Child $25/mo (ages 12 & under), or Perio $50/mo (for patients with periodontal disease). All plans include a one-time $99 activation fee.

Member 7

Name*

Date of Birth*

Dental Membership Type*

Select your membership type. Adult $35/mo (ages 13+), Child $25/mo (ages 12 & under), or Perio $50/mo (for patients with periodontal disease). All plans include a one-time $99 activation fee.

Member 8

Name*

Date of Birth*

Dental Membership Type*

Select your membership type. Adult $35/mo (ages 13+), Child $25/mo (ages 12 & under), or Perio $50/mo (for patients with periodontal disease). All plans include a one-time $99 activation fee.

Consent & Payment

Signature*

Activation Fee(s)

Price: $0.00

Gentle Creek Dental Membership

Price: $0.00

IMPORTANT BILLING INFORMATION: Today you will be charged the $99 activation fee(s) which includes your first month of membership coverage. 30 days from today, your selected monthly membership fee will automatically be charged to this payment method. This recurring membership fee will continue monthly until cancelled.

Credit Card

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