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AMERICA'S PRE-PAID DENTAL PLAN

Exclusively Offered by Dr. Rob Rainey

Full Name
Email Address (Required)
Phone Number (Required)
Address
- Street Address
- Address Line 2
- City
- State / Province / Region
- Postal / Zip Code
- Country
CHECK PLAN CHOSEN
FEE CALCULATION INSTRUCTIONS
CALCULATE INITIAL FEE AMOUNT
CHECK AND COMPLETE INFORMATION FOR ALL DEPENDENTS TO BE COVERED:

SPOUSE: Full Name ______________________________________________ M/F _____ DOB ___________________________
CHILD: Full Name ________________________________________________ M/F _____ DOB ___________________________
CHILD: Full Name ________________________________________________ M/F _____ DOB ___________________________
CHILD: Full Name ________________________________________________ M/F _____ DOB ___________________________

APPLICATION

(Type in your answers)

INITIAL FEE CALCULATOR

America's Dental Associates billing dates are January 1st and July 1st of each year.

To calculate your Initial Fees figure the # of months from the first of next month to

the end of the year. Multiply that # times the Monthly Fee Amount based on the

coverage you've chosen and enter it under the Total Initial Fee.

PLAN MONTHLY # OF TOTAL

COVERAGE___ FEES X MONTHS = INITIAL FEE

Individual $13.00 X ______ = $_________

Individual + 1 $16.50 X ______ = $_________

Family (3 or more) $24.00 X ______ = $_________

3 WAYS TO ENROLL!

1. CLICK HERE to request an application be sent to you via email. Use the Initial Fee Calculator below to calculate the amount of the check you'll need to include when you return you application. Be sure and include your email address.

2. You can pick up an application at Dr. Rob Rainey's office. Complete it and mail it along

with your check made payable to America's Dental Associates for the Initial Fee.

3. Or you can complete the application at the bottom of this page and SUBMIT it directly to America's Dental Associates. You can make your payment Online through our Secure Payment Processor.

IT'S YOUR CHOICE, WHICHEVER WORKS BEST FOR YOU!!

NOTE:

The Total Initial Fee will be the amount you'll enter on the application, if you're

requesting a paper application via email or picking one up at Dr. Rainey's Office.

If enrolling on line, include the information on the application below,