SDC Dental Savings Plan - Plan Confirmation

Is this the correct address?

Yes, proceed.

Proceed anyway.

No, try again.

[MM_Member_Decision isMember="false"]

Join Now And Start Saving Right Away

[MM_Form type='checkout'] [MM_Form_Message type='error']

Account

Billing

Payment

Confirmation

[MM_Order_Decision membershipId='2']

next: Billing Information

[/MM_Order_Decision][MM_Order_Decision membershipId='3']

next: Billing Information

[/MM_Order_Decision][MM_Order_Decision membershipId='4']

next: Billing Information

[/MM_Order_Decision]

Good Choice!

[MM_Order_Decision membershipId='2'] indiv

[/MM_Order_Decision] [MM_Order_Decision membershipId='3'] twoindiv

[/MM_Order_Decision] [MM_Order_Decision membershipId='4']

[/MM_Order_Decision]

Savings Start Immediately

NO waiting periods
NO maximums
NO exclusions
NO hassles

[MM_Form_Section type="accountInfo"] [MM_Order_Decision membershipId='2']

Account Information

First Name: [MM_Form_Field type="input" name="firstName" tabindex="-1" class="required errorr" customAttributes='placeholder="First Name"']

Last Name: [MM_Form_Field type="input" name="lastName" tabindex="-1" class="required errorr" customAttributes='placeholder="Last Name"']

Phone: [MM_Form_Field type='input' name='phone' customAttributes='placeholder="Phone Number"' class="required errorr"]

Email: [MM_Form_Field type="input" name="email" tabindex="-1" class="required errorr newpeep" customAttributes='placeholder="example@email.com"']

Password: [MM_Form_Field type="input" name="password" tabindex="-1" class="required errorr" customAttributes='placeholder="Password"']

Date of Birth: [MM_Form_Field type='custom' id='1' isRequired='true' class='dob'] [MM_Form_Field type='custom' id='2' isRequired='true' class='dob'] [MM_Form_Field type='custom' id='3' isRequired='true' class='dob']

[/MM_Order_Decision] [MM_Order_Decision membershipId='3']

Primary Member
Second Member

Account Information

First Name: [MM_Form_Field type="input" name="firstName" tabindex="1" class="required errorr" customAttributes='placeholder="First Name"']

Last Name: [MM_Form_Field type="input" name="lastName" tabindex="3" class="required errorr" customAttributes='placeholder="Last Name"']

Phone: [MM_Form_Field type='input' name='phone' customAttributes='placeholder="Phone Number"' class="required errorr"]

Email: [MM_Form_Field type="input" name="email" tabindex="-1" class="required errorr newpeep" customAttributes='placeholder="example@email.com"']

Password: [MM_Form_Field type="input" name="password" tabindex="-1" class="required errorr" customAttributes='placeholder="Password"']

Account Information

Second Member

(2) First Name: [MM_Form_Field type='custom' id='8' isRequired='true' value="0" tabindex="-1" class="required errorr"]

(2) Last Name: [MM_Form_Field type='custom' id='9' isRequired='true' value="0" tabindex="-1" class="required errorr"]

[/MM_Order_Decision] [MM_Order_Decision membershipId='4']

Primary Member
Family Members

Account Information

First Name: [MM_Form_Field type="input" name="firstName" tabindex="-1" class="required errorr" customAttributes='placeholder="First Name"']

Last Name: [MM_Form_Field type="input" name="lastName" tabindex="-1" class="required errorr" customAttributes='placeholder="Last Name"']

Phone: [MM_Form_Field type='input' name='phone' customAttributes='placeholder="Phone Number"' class="required errorr"]

Email: [MM_Form_Field type="input" name="email" tabindex="-1" class="required errorr newpeep" customAttributes='placeholder="example@email.com"']

Password: [MM_Form_Field type="input" name="password" tabindex="-1" class="required errorr" customAttributes='placeholder="Password"']

Account Information

How many are in your family?

[MM_Form_Field type='custom' id='4' isRequired='false' class='familyselector' tabindex="-1"]

Second Family Member

(2) First Name: [MM_Form_Field type='custom' id='8' isRequired='true' value="0" class="required errorr"]

(2) Last Name: [MM_Form_Field type='custom' id='9' isRequired='true' value="0" class="required errorr"]

Third Family Member

(3) First Name: [MM_Form_Field type='custom' id='10' isRequired='false' class="required errorr"]

(3) Last Name: [MM_Form_Field type='custom' id='11' isRequired='false' class="required errorr"]

Fourth Family Member

(4) First Name: [MM_Form_Field type='custom' id='12' isRequired='false' class="required errorr"]

(4) Last Name: [MM_Form_Field type='custom' id='13' isRequired='false' class="required errorr"]

Fifth Family Member

(5) First Name: [MM_Form_Field type='custom' id='14' isRequired='false' class="required errorr"]

(5) Last Name: [MM_Form_Field type='custom' id='15' isRequired='false' class="required errorr"]

Sixth Family Member

(6) First Name: [MM_Form_Field type='custom' id='16' isRequired='false' class="required errorr"]

(6) Last Name: [MM_Form_Field type='custom' id='17' isRequired='false' class="required errorr"]

Seventh Family Member

(7) First Name: [MM_Form_Field type='custom' id='18' isRequired='false' class="required errorr"]

(7) Last Name: [MM_Form_Field type='custom' id='19' isRequired='false' class="required errorr"]

Eighth Family Member

(8) First Name: [MM_Form_Field type='custom' id='20' isRequired='false' class="required errorr"]

(8) Last Name: [MM_Form_Field type='custom' id='21' isRequired='false' class="required errorr"]

Ninth Family Member

(9) First Name: [MM_Form_Field type='custom' id='22' isRequired='false' class="required errorr"]

(9) Last Name: [MM_Form_Field type='custom' id='23' isRequired='false' class="required errorr"]

Tenth Family Member

(10) First Name: [MM_Form_Field type='custom' id='24' isRequired='false' class="required errorr"]

(10) Last Name: [MM_Form_Field type='custom' id='25' isRequired='false' class="required errorr"]

[/MM_Order_Decision] [/MM_Form_Section]

next: Payment Information

back: Account Information

[MM_Form_Section type='shippingInfo']

Shipping Address

Address: [MM_Form_Field name='shippingAddress' customAttributes='placeholder="Shipping Address"' class="required errorr"]

City: [MM_Form_Field name='shippingCity' customAttributes='placeholder="Shipping City"' class="required errorr"]

State: [MM_Form_Field name='shippingState' customAttributes='placeholder="Shipping State"' class="required"]

Zip: [MM_Form_Field name='shippingZipCode' customAttributes='placeholder="Shipping Zip Code"' class="required errorr"]

Country: [MM_Form_Field name='shippingCountry'] [/MM_Form_Section]

[MM_Form_Section type="billingInfo"]

Billing Address

[MM_Form_Field name='shippingSameAsBilling']Billing is same as Shipping

Address: [MM_Form_Field name='billingAddress' customAttributes='placeholder="Billing Address"' tabindex="-1" class="required errorr"]

City: [MM_Form_Field name='billingCity' customAttributes='placeholder="Billing City"' tabindex="-1" class="required errorr"]

State: [MM_Form_Field name='billingState' customAttributes='placeholder="Billing State"' tabindex="-1" class="required"]

Zip: [MM_Form_Field name='billingZipCode' customAttributes='placeholder="Billing Zip Code"' tabindex="-1" class="required errorr"]

Country: [MM_Form_Field name='billingCountry' tabindex="-1"] [/MM_Form_Section]

next: confirmation

Back: Billing Information

[MM_Form_Section type='billingInfo']

Payment Details

Credit Card: [MM_Form_Field name='ccNumber' customAttributes='placeholder="Credit Card Number"' class="required errorr"]

Security Code: [MM_Form_Field name='ccSecurityCode' customAttributes='placeholder="Security Code"' class="required errorr"]

Expiration Date: [MM_Form_Field name='ccExpirationDate']

*If paying by check or money order, please submit completed enrollment application along with payment via mail.

Enrollment Application

[/MM_Form_Section]

[MM_Form_Section type='coupon']

Provider ID Number

(optional)

[MM_Form_Field name='couponCode'] Apply ID [MM_Form_Field type='custom-hidden' id='5' isRequired='false' class=''] [MM_Form_Message type='couponSuccess'] [MM_Form_Message type='couponError']

Affiliated Providers: While facilitating enrollment, please inform your new member(s) that:

Welcome email and payment receipt will be sent to their email.
Membership kit, including Welcome Letter, copy of Member Terms & Conditions, and Plan ID cards will arrive at their address in 7-10 business days.

[/MM_Form_Section]

Back: Payment Information startover

Order Details

[MM_Order_Decision membershipId='2'] indiv

Product Price: $76.00 [/MM_Order_Decision] [MM_Order_Decision membershipId='3'] twoindiv

Product Price:$96.00 [/MM_Order_Decision] [MM_Order_Decision membershipId='4']

Product Price:$116.00 [/MM_Order_Decision] [MM_Order_Decision isDiscounted='true'] Discount: [MM_Form_Data name='discount'] [/MM_Order_Decision] Total Price: [MM_Form_Data name='totalPrice'] per year

Savings Start Immediately

NO waiting periods
NO maximums
NO exclusions
NO hassles

Submit Order

Terms and Conditions - Member

Keep on Smilin' Assurance Terms and Conditions - Member

[MM_Form_Field type='custom' id='6' isRequired='true' class='readtandc'] Patient has read the Terms and Conditions

[MM_Form_Button type='all' label='Submit Order' color='orange']

[/MM_Form]

[/MM_Member_Decision] [MM_Member_Decision isMember="true"]

[MM_Form type='checkout'] [MM_Form_Message type='error']

[MM_Order_Decision membershipId='2']

Transaction Error

There was an error while processing your transaction. If you need help please don't hesitate to call our Member Engagement Specialists at (888) 644-5401.

[/MM_Order_Decision] [MM_Order_Decision membershipId='3']

Product Price:$96.00 [MM_Form_Section type="accountInfo"] First Name: [MM_Form_Field type="input" name="firstName"] Last Name: [MM_Form_Field type="input" name="lastName"] Email: [MM_Form_Field type="input" name="email"]

Password: [MM_Form_Field type="input" name="password"] Phone: [MM_Form_Field type="input" name="phone"] [/MM_Form_Section]

Upgrade Information

Second Member

(2) First Name: [MM_Form_Field type='custom' id='8' isRequired='true' value="0" tabindex="-1" class="required errorr"]

(2) Last Name: [MM_Form_Field type='custom' id='9' isRequired='true' value="0" tabindex="-1" class="required errorr"]

[MM_Form_Section type='billingInfo']

New Billing Info

Address: [MM_Form_Field name="billingAddress"]

City: [MM_Form_Field name="billingCity"]

State: [MM_Form_Field name="billingState"]

Zip Code: [MM_Form_Field name="billingZipCode"]

Country: [MM_Form_Field name="billingCountry"]

Credit Card: [MM_Form_Field name='ccNumber' customAttributes='placeholder="Credit Card Number"' class="required errorr"]

Security Code: [MM_Form_Field name='ccSecurityCode' customAttributes='placeholder="Security Code"' class="required errorr"]

Expiration Date: [MM_Form_Field name='ccExpirationDate']

[/MM_Form_Section]

Order Confirmation

Total: [MM_Form_Data name='totalPrice'] per year

Terms and Conditions - Member

Keep on Smilin' Assurance Terms and Conditions - Member

[MM_Form_Field type='custom' id='6' isRequired='true' class='readtandc'] Patient has read the Terms and Conditions

[MM_Form_Button type='all' label='Submit Upgrade' color='orange']

[/MM_Order_Decision] [MM_Order_Decision membershipId='4']

Product Price:$116.00 [MM_Form_Section type="accountInfo"] First Name: [MM_Form_Field type="input" name="firstName"] Last Name: [MM_Form_Field type="input" name="lastName"] Email: [MM_Form_Field type="input" name="email"]