AVS Dental Enrollment Form

First Name *

Middle Initial

Last Name *

Gender Male Female

Date of Birth

Address 1 *

Address 2

City *

State *

Zip Code *

Home Phone *

Work Phone

Email *

Employer Name

How did you hear about us?

Additional Enrollees

First Name

MI

Last Name

DOB

Relationship

Plan Type *

Plan Type	Monthly Payment* **	Annual Payment*
Single	$11 plus a one-time $19 Reg. Fee	$99 plus a one-time $19 Reg. Fee
Couple	$18 plus a one-time $19 Reg. Fee	$179 plus a one-time $19 Reg. Fee
Family	$20 plus a one-time $19 Reg. Fee	$199 plus a one-time $19 Reg. Fee

*All monthly and one year plans require a one-time $19 registration fee.
** The monthly payment option requires a one year minimum contract.

RX/Vision Plan Add the AVS RX/Vision plan to my AVS Dental Plan for an additional $75/year for yearly payments, or $7/month for monthly payments.

Total Charges

$

Payment Method *

Credit Card

Email Form (an AVS representative will call me to follow up)

Pay by Check (an AVS representative will call me once my check is received)

Please make checks out to AVS Dental Plan and mail to

424 Rosevale Ave, Ronkonkoma, NY 11779

Credit Card Type

Credit Card #

Expiration Date /

CVV Code What is this?

Comments

Include name of referring friend/dentist and AVS code, if applicable.

Cancellation Policy:

Membership fees are refundable within five (5) days of your enrollment. Requests must be made by phoning us at 877.327.8376. Following the five-day period, requests must be received in writing and, if approved, there will be a 30% processing fee and monthly prorate. All plans require a one-year minimum membership. Any additional years purchased can be refunded before that year of membership begins, and the price of time used will be adjusted accordingly. The $19 registration fee is non-refundable. All monthly plan options require a one-year contract; after the full year is completed, monthly payments can be stopped at any time.

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