Please provide us with your name, mailing address, date of birth, and social security
Social Security #
If paying by check please skip the credit card information, select your annual payment
choice then print the whole enrollment form, filled out. Mail it along with appropriate
P.O. Box 7937, Stockton, CA. 95267
If paying by credit card please fill in the following information:
Please select annual payment choice:
Member & 1 dependent
Please enter the name and office number of the dentist you are considering using.
This information can be found on the ‘find a dentist’ tab. Keep in mind you can visit
any of the dentists in our extensive network.
Dental Office Name & Number:
On behalf of the above named individuals, I hereby apply for enrollment in CDN and certify that the above information is true and correct.
NOTICE: by completing this application you are agreeing to have any dispute with the plan, including medical malpractice, decided by neutral arbitration and you are giving up your constitutional right to a jury or court trial. See the combined evidence of coverage and disclosure form for details.
When finished filling out all the appropriate information please click the submit