2023 Smilist ONE Couple Plan

You are one step closer to enrolling in our comprehensive dental membership program! We make receiving high-quality dental care easy, affordable and convenient for you.

Let's get started!
Personal Information

Tell us a little about yourselves.
Date*

MonthDayYear
Date
Patient Name*

First NameLast Name
Phone Number*
Format: (000) 000-0000.
Email Address*

Confirmation Emailexample@example.com
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Patient Date of Birth*

MonthDayYear
Date
YesNo
Preferred Smilist Dental Location*
Partner Name*

Partner First NamePartner Last Name
Partner Phone Number*
Format: (000) 000-0000.
Partner Email Address*

Confirmation Emailexample@example.com
Partner Address*

Street Address

Street Address Line 2

CityState

Zip Code
Partner Date of Birth*

MonthDayYear
Date
YesNo
Preferred Smilist Dental Location*
Membership & Payment Details

Select your membership subscription and enter your payment details. You will be able to confirm your information on the next page.

Subscription Type*

Couple - Monthly Plan($55.00 for each month)

Couple - Annual Plan($605.00 for each year)

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Payer Full Name*

First NameLast Name

Enrollment Confirmation

Please take a moment and confirm that the below information is accurate.
Enrollment Date: {date}

Subscription Type: {subscriptionType} Smilist ONE Couple Plan

Payer Name: {payerFull}

Patient Name: {patientName}

Existing Patient: {areYou}

Patient Phone Number: {phoneNumber}

Patient Email Address: {emailAddress}

Patient Address: {address}

Patient Date of Birth: {patientDate}

Preferred Smilist Dental Location: {preferredSmilist}

Partner Name: {partnerName}

Existing Patient: {areYou32}

Partner Phone Number: {partnerPhone}

Partner Email Address: {partnerEmail}

Partner Address: {partnerAddress}

Partner Date of Birth: {partnerDate}

Partner Preferred Smilist Dental Location: {preferredSmilist39}

If everything is correct, please click 'ENROLL' to process your payment.

Thank you {patientName} for enrolling in the Smilist ONE Membership program!
Please verify that you are human*
TERMS & CONDITIONS: By clicking on ENROLL, you agree to the following terms and conditions: The Smilist ONE Membership is NOT A DENTAL INSURANCE PLAN and not intended to be a substitute for a dental insurance plan. There is a 1-year commitment per Smilist ONE Membership and if Membership is canceled before the end of the 1 year, the participant is responsible for the remaining balance. After the 1 year commitment, the Membership can be canceled at any time. The credit card on file will be automatically charged monthly or annually, depending on the Membership selected, until canceled. The Membership is non-transferrable and no refunds will be issued if the participant decides not to or is unable to, utilize the Membership, or for any reason. The Smilist ONE Membership is only valid for services rendered at an affiliated participating Smilist Dental office and cannot be used anywhere else.
Should be Empty:

Personal Information

Membership & Payment Details

Enrollment Confirmation