Registration for Individual and Family Plans

To register as a member please fill out the form below:

Last Name:

First Name:

Date of Birth:
(DOB of Individual or Primary Family Member)

(For example: 06/23/1955)

Street Address:

City:

State:

Zip:

Phone Number:

Digits Only: 123 456 7890

Your Email:
(This will be your Member ID, and our primary means of communication with you)

Retype Email:

MEMBERSHIP COST - PAYMENT OPTIONS

All first time members are eligible for a SIX MONTH trial period at cost of $35.00. During the first 90 days, you may cancel for any reason, and we will REFUND your $35.00.

All membership payments, including the $35.00 trial period cost, will be paid via PayPal. Please Note: If you do not already have a PayPal account, you can apply for one below.

I AGREE:

Yes
No

PLEASE SELECT A PAYMENT OPTION that will apply beyond the SIX MONTH trial period:

Please Select Enrollment Status:
(Family Membership includes all household members)

Semi-Annual

Individuals	$35.00
Family/Household	$55.00

All member payments are processed by PayPal. If you are not already a member of PayPal, you will be able to enroll as part of this application, and link your debit or credit card, or your bank account to your free and secure PayPal account that will be recognized at many web sites.

Membership fee payments will recur automatically on a semi-annual basis. A member can cancel membership payments by notifying NYDN or PayPal. Contact us at any time if you have questions.

Were you referred by an AGENT or plan representative?

Please enter the LAST FOUR DIGITS of your Social Security number for password ID purposes. This will be kept confidential and used for future changes member may need to make:

Retype the LAST FOUR DIGITS of your Social Security number:

I have read and I accept the member agreement and am ready to join New York Dental Network, LLC.

Yes No