Club Dental Membership Card – Order Page – Spencer Health Network

Club Dental Membership Card - Order Page

Club Dental Membership Card Order Page

Welcome to the NEW and IMPROVED Club Dental order form! If you have any questions while filling out the form, please give us a call for assistance 9AM-5PM EST at 416-512-1616

Step 1 of 3

Type of Membership*
- Single ($40.00 annual payment + Applicable Taxes)
- Couple ($60.00 annual payment + Applicable Taxes)
- Family (80.00 annual payment + Applicable Taxes)
*Cost of the membership is a one time annual payment due at the time of ordering. All memberships are one year in length*
Start Date*
MM slash DD slash YYYY

*Expiry Date will be one year after the Start Date*

Name*
First Last
Additional Family Member Names

*If you are entering multiple family members, please separate them with a comma.
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Email*
How did you find us?

Promo Code
Total
$ 0.00 CAD
Credit Card*

American Express
Discover
MasterCard
Visa
Supported Credit Cards: American Express, Discover, MasterCard, Visa
Card Number Expiration Date Security Code Cardholder Name
Auto-Renew Your Membership?*
- Yes
- No
Name
This field is for validation purposes and should be left unchanged.