Smilist One PREMIER Child 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!
Parent/Guardian Personal Information

Tell us a little about yourself. Parent/Guardian must be at least 18 years old to enroll child(ren).
Date*

MonthDayYear
Date
Parent/Guardian 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
Parent/Guardian Date of Birth*

MonthDayYear
Date
YesNo
Preferred Smilist Dental Location*
Children's Information

Enroll your children into a Smilist ONE Child Plan. Select how many children you choose to enroll and provide us their names and birthdates.
How Many Children Are You Enrolling?*
If no selection is made the default is one child.
Enter your Child(ren's) Full Name and Date Of Birth*
ChildrenEnrolled
ChildrenAnnual
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*

Smilist One PREMIER Child Monthly Plan($30.00 for each month)

Smilist One PREMIER Child Annual Plan($360.00 for each year)

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

Enrollment Confirmation

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

Subscription Type: {subscriptionType} Smilist One PREMIER Child Plan

Parent/Guardian Name: {parentguardianName2}

Parent/Guardian Phone Number: {phoneNumber}

Parent/Guardian Email Address: {emailAddress}

Parent/Guardian Address: {address}

Parent/Guardian Date of Birth: {parentguardianDate}

Is Your Child An Existing Patient: {isYour}

Preferred Smilist Dental Location: {preferredSmilist}

Number Of Children: {numOfKids}

Name Of Child(ren): {enterYour}

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

Thank you {patientName} for enrolling in the Smilist One PREMIER 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 Smilist Dental office and cannot be used anywhere else.
Should be Empty:

Parent/Guardian Personal Information

Children's Information

Membership & Payment Details

Enrollment Confirmation