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Individual Enrollment

Please use the secure form below to sign up for your Individual & Senior plans. If you are a new patient, a member of our staff will be in touch with you to go over the plan with you and collect some additional information.

Indent Plan
Your First Name:
Your Last Name:
Your Phone:
Your Email:
Your Address:
Your City:
Your State:
Your Zip:
Member Status:
New Patient     Existing Patient
How Did You Hear About InDent?:

Choose Your Plan:

Please enter your additional family member(s):

Payment Information

Billing First Name:
Billing Last Name:
Billing Address:
Billing City:
Billing State:
Billing Zip:
Price of plan:

Card Number
Expiration Date

Card CVV

*We will contact you to confirm your information and plan.