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# ____________
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Please Mail Membership payment and completed application to:
Senior Dental Service,
Inc.
3221 Waialae Ave., Suite. 374
Honolulu, Hawaii 96816
Phone: (808) 735-5557