First Name:
Last Name:
Mailing Address:
Street Address:
City:
State:
Zip:
Home Phone:
Work Phone:
Employer:
How Long?
Employer Address:
City/State:
Email:
Driver's License #
Sex:
Male
Female
Date of Birth
Marital Status:    
Spouse's Name:
Spouse's Employeer:
   
Date of Birth
Referred By:    
Dependants to Be Considered
Name
Age
Date of Birth
   

Stone Dental Monthly Plan Rates - 36 Month Contract
(Please choose one)
COMPANY PLAN RATES DIFFER ACCORDING TO GROUP SIZE

Plan I
Plan II
Plan III
Plan IV
Single $38.96 $31.00 $24.46 $16.50
Couple $48.96 $41.00 $29.96 $22.00
Couple w/Ortho $74.96 $60.00 $55.96 $41.00
Family 4 or Less $78.96 $65.00 $50.96 $37.00
Family 5 or More $89.96 $74.00 $57.46 $41.00
Family 4 or more w/Ortho $94.96 $79.00 $66.96 $51.00
Family 5 or more w/Ortho $109.96 $92.00 $77.46 $59.00
    
Terms & Conditions
(Please click here to read carefully)
By typing YES in each of the following five (5) blanks, you agree that  you have read, understood, and agree with each Term and Condition.

 

TYPE YES HERE

I have read "Term I" and agree with it. Click here to read Term I

I have read "Term II" and agree with it. Click here to read Term II

I have read "Term III" and agree with it. Click here to read Term III

I have read "Term IV" and agree with it. Click here to read Term IV

I have read "Conditions" and agree with it. Click here to read Conditions