Gentle Care Membership Update | Gentle Creek Dental

Gentle Creek Dental Membership Plan Update

for existing members

"*" indicates required fields

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.