MINT Discount Plan

Discount Plan
Choose Your Individual Plan*
Choose Number of Additional Members
Office*
Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Street Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*
Alternate Phone
E-mail*
Additional Members Information
Second Member Full Name*

First NameLast Name
Third Member Full Name*

First NameLast Name
Fourth Member Full Name*

First NameLast Name
Fifth Member Full Name*

First NameLast Name
Sixth Member Full Name*

First NameLast Name
Seventh Member Full Name*

First NameLast Name
Total Yearly Cost
First Payment at Office Visit
The Mint Discount Plan provides discounts to enrolled plan members for a complete range of dental services provided by Mint Dentistry. Mint Discount Plan members are responsible for paying for any dental services rendered at the plan rate. This program is both non refundable and non transferable. Any enrolled member is responsible for the initial fee of $140, plus $125 for each additional family member. If a member wants to cancel, they must do so 30 days before the yearly renewal date. Please email discountplan@mintdentistry.com if you wish to cancel or have any questions.
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Discount Plan