Welcome To Primecare Dental Plan

To purchase one of Primecare Dental's Dental Plans please fill out our secure form below.
(Bolded fields are required)

Contact Information
First Name		Date of Birth (month/day/yr,i.e. 01/15/1975)

Last Name		Phone (Res.)

MI		Phone (Bus.)

Address		E-mail

City		Employer

State

Zip


Spouse, Dependent's Info
Spouse's First Name		Last Name

MI		DOB (month/day/yr, i.e. 01/15/1975)

Dependent's First Name		Last Name

MI		DOB (month/day/yr, i.e. 01/15/1975)

Dependent's First Name		Last Name

MI		DOB (month/day/yr, i.e. 01/15/1975)

Dependent's First Name		Last Name

MI		DOB (month/day/yr, i.e. 01/15/1975)


WELCOME PLAN Info


Select Plan Premium
Individuals
Subscriber		$125
Subscriber +1 dependent		$156
Subscriber + family		$175
Seniors
Subscriber		$115
Subscriber +1 dependent		$146
All plans include $10 processing fee

Comments


Credit Card Info
Payment Method		Credit Card Number Do not use spaces

		Expiration Date (MM/YYYY)

Problems with transactions ?
E-mail : info@primecaredental.net or Call : 1.800.937.3400
(M-F, 9a.m.-5p.m. PST)