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Dental Services
Please provide us with your name, mailing address, date of birth, and social security number:
First name
Last name
Mailing Address
City
State
Zip
Phone
Email address
Social Security #
DOB mm/dd/yyyy
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 payment to:
California Dental
P.O. Box 7937, Stockton, CA. 95267
If paying by credit card please fill in the following information:
VISA
Master Card
AMEX
Discover
Cardholder's Name
Cardholder Address
Card Number
Expiration Date
Security code
Please select annual payment choice:
Single
$70.00
Member & 1 dependent
$110.00
Family
$150.00
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.
I agree
When finished filling out all the appropriate information please click the submit button