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Applicant’s Information

Valid Email Address
Comfirm Email Address*
Last Name
First Name
Date of Birth
Home Address include APT#
Zip Code
Home Phone
Cell Phone
Dependants Names & Dates of Birth (D.O.B)
1)D.O.B. 2)D.O.B.
3)D.O.B. 4)D.O.B.
5)D.O.B. 6)D.O.B.
7)D.O.B. 8)D.O.B.
Payment Information
How will you be paying?
Credit Card #
Expiration Date
Name on card

Complete only for Bank Draft only*   (Initial draft begins immediately and thereafter, on the 15th of each month) 

Routing *
Account# *
Check# *
Driver’s License#

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How will you be paying?   Monthlyor  Annually Semi-Annual
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I wish to enroll with American Dental Care Partners, Inc. I understand this is an annual agreement and that all necessary dental services will be provided as described in the members fee schedule. This plan will automatically renew every year unless otherwise notified. If paying for 6 months, filling out this application authorizes American Dental Care Partners, Inc. to automatically debit the member’s remaining 6 months for the one-year agreement from the account that was used to pay for the first 6 months. I have received a copy of the member’s fee schedule. If the member cancels membership with American Dental Care Partners, Inc. within the first 30 days after the effective date of enrollment in the plan, the member shall receive a reimbursement of all periodic charges upon return of the discount card to American Dental Care Partners, Inc. Cancellations by telephone will not be accepted. The cancellation must be in writing to

American Dental Care Partners, Inc., 11221 Katy Freeway, Suite 209, Houston, TX 77079. Or fax 713-784-6928.

Note* American Dental Care Partners, Inc. does not share and sell your email or any personal information. 

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DISCLOSURE: This plan is NOT insurance. The plan provides discounts at certain health care providers for medical services. The plan does not make payments directly to the providers of medical services. The plan member is obligated to pay for all health care services but will receive a discount from those health care providers who have contracted with the discount plan organization.
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