Individual Enrollment

Please use the secure form below to sign up for your Individual & Family 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
	Same as above
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.

Payment Information