Phone Plan Holder Information Plan Holder First Name Email Plan Holder Last Name Phone Street Address State - Select Province/State - Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon ==================== Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Gender Gender Male Female Prefer Not to Say Zip Birthday Plan Start Date How many additional family members will be on your plan? Number of People OneTwoThreeFourFive The Gentle Care Membership plan is valid only at Gentle Creek Dental. Co-payments must be paid at the time of service. Any fees not paid at the time of service will be billed at usual and customary fees. This plan is nonrefundable. No refunds will be given if a plan participant chooses not to use their dental plan. The plan discount applies to dental services only; products are not included. The range of discounts will vary depending on the treatment provided. Rates are subject to change annually. For orthodontic treatment, the participant must remain a plan participant for the entire duration of orthodontic treatment or will be liable for the full orthodontic service fee. You may add additional family members to the plan at any time during the duration of the contract. Family members are defined as the spouse of the plan participant and dependent children who live in the participant’s household, or away at school, and under the age of 26. This plan is non-transferable – family members cannot be substituted for another participant covered by this plan. If for any reason a plan participant is referred to a specialist, the specialist will not offer this discount. Should dental treatment be required following any type of injury where a lawsuit, outside medical care, disability or workman’s comp type insurance(s) are involved, this discount plan cannot be used. The Gentle Care Membership Plan is NOT INSURANCE and is not intended to replace health insurance. This plan does not meet the minimum creditable coverage requirements under M.G.L c 111M and 956 CMR 5.00. This plan is not a Qualified Health Plan under the Affordable Care Act. This offer cannot be combined with any other offers and is valid for one year from date of registration. I agree to the terms & conditions of the Gentle Care Membership Plan *