Sign Up for Affordable Membership Sign Up for Our Affordable Membership Plan Simply complete the form below to sign up for your membership plan! Name* First Middle Initial Last Social Security Number*Please enter a value between 9 and 9.Date of Birth* Address* Street Address City State / Province / Region ZIP / Postal Code Email* Phone*What Membership Works Best for You?*SingleCoupleFamilyDependent Name* First Middle Initial Last Relationship*Date of Birth* Dependent Name - Child #1 First Middle Initial Last Date of Birth - Child #1 Dependent Name - Child #2 First Middle Initial Last Date of Birth - Child #2 Dependent Name - Child #3 First Middle Initial Last Date of Birth - Child #3 Will you need coverage for more than 3 children?Each additional child is only $18 per month. YesNoDependent Name - Child #4 First Middle Initial Last Date of Birth - Child #4 Will you need coverage for more than 4 children?YesNoDependent Name - Child #5 First Middle Initial Last Date of Birth - Child #5 TotalYour monthly billing cycle will begin once you complete registration with one of our friendly dental staff. $0.00 This iframe contains the logic required to handle Ajax powered Gravity Forms. “Dr. Moore and his staff are amazing, fun, caring, and offer a great enviornment” – Shane V., Google Review READ MORE REVIEWS Have a Dental Insurance Plan? We accept any dental insurance plan. Call our offices today to find out more information at 479-484-5050. SCHEDULE AN APPOINTMENT