Member Information

Select Provider  

Name (primary member)     Date of Birth:

SSN#     Phone     Address

City    Zip

Name (dependent) 

SSN#      Date of Birth:

Membership Payment Options:

Select mode of payment: 

Check or Money Order payable to Senior Dental Service, Inc
                            Total Amount of Membership payment enclosed: $

Please Charge my Discover MasterCard Visa

For the Amount of  $    Account number   

Expiration date        Card holder Signature: __________________________

I have reviewed a summary of the SDP/ADP & Co-payments (see fee schedule). By selecting "I agree" below,
I agree to the terms and conditions (I.e. cancellation & refund, co-payments, and specialty referral policies).
As a member of SDP/ADP, I authorize SDS, Inc. to periodically review my dental records.

I agree         I do not agree

Signature:___________________________     Date:

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for office use only
Check# ______________ Order taken by: ________________ Membership# ____________

Please Mail Membership payment and completed application to:

Senior Dental Service, Inc.
3221 Waialae Ave., Suite. 374
Honolulu, Hawaii 96816
Phone: (808) 735-5557