Affordable Dental Membership Plan | Fort Smith, Arkansas

Sign Up for Affordable Membership

Simply complete the form below to sign up for your membership plan!

Name*
First Middle Initial Last
Social Security Number*
Please enter a number from 9 to 9.
Date of Birth*
Date Format: MM slash DD slash YYYY
Address*
Street Address City State / Province / Region ZIP / Postal Code
Email*
Phone*
What Membership Works Best for You?*
Dependent Name*
First Middle Initial Last
Relationship*
Date of Birth*
Date Format: MM slash DD slash YYYY
Dependent Name - Child #1
First Middle Initial Last
Date of Birth - Child #1
Date Format: MM slash DD slash YYYY
Dependent Name - Child #2
First Middle Initial Last
Date of Birth - Child #2
Date Format: MM slash DD slash YYYY
Dependent Name - Child #3
First Middle Initial Last
Date of Birth - Child #3
Date Format: MM slash DD slash YYYY
Will you need coverage for more than 3 children?
Each additional child is only $18 per month.
Dependent Name - Child #4
First Middle Initial Last
Date of Birth - Child #4
Date Format: MM slash DD slash YYYY
Will you need coverage for more than 4 children?
Dependent Name - Child #5
First Middle Initial Last
Date of Birth - Child #5
Date Format: MM slash DD slash YYYY
Total
Your monthly billing cycle will begin once you complete registration with one of our friendly dental staff.
$0.00

“Dr. Moore and his staff are amazing, fun, caring, and offer a great enviornment”

– Shane V., Google Review

We accept any dental insurance plan. Call our offices today to find out more information at 479-484-5050.