AVS Dental Renewal Form

avs_dental_discount_5yr

Home

Enroll / Renew

Renewal Form

Renew with AVS Dental Plan

AVS Dental Plan gives you the flexibility to renew at your convenience. We’ve set up one-, three-, and five-year discount dental plans, so you can choose the right one for your budget and lifestyle.

Please feel free to contact us if you have any questions about our discount dental plans.

Please fill in the below fields as completely as possible.(*) indicates a required field.

Member ID

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

Last Name

DOB

Relationship

Plan Type *

Plan Type	Monthly Payment*	Annual Payment*
Single	$11	$99
Couple	$18	$179
Family	$20	$199

* 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.

As a member you are eligible to receive a great vision and prescription drug plan at a significant discount.


1.877.327.8376
AVS is here to help. Call us now and let us help you start saving today.

Call AVS Dental Today at 1.877.327.8376