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new dental choice Sign-up Form

To enroll in a New Dental Choice plan, simply complete the following information:

  • Select the type of plan you are electing, individual or family
  • Complete the enrollment form to provide membership details and contact information
  • Securely authorize payment for either a yearly or monthly basis
Once your enrollment is processed you will receive an email confirmation that includes your Member ID number and you can begin using your membership immediately. The first business day after your enrollment you will be mailed your member ID cards and plan details that should arrive within five to seven business days.

If you are currently a member, please call us at (866) 953-7645 to update your information.

Please note: We currently do not offer New Dental Choice in Alaska, Hawaii, Maine, Montana, New Hampshire, Rhode Island, South Dakota, Vermont, Washington and Wyoming.

Choose Dental Plan and Payment Plan

How would you like to be billed for this membership?

Line Item Price
New Dental Choice Individual Plan (Annual) $96.00
** One time activation fee $10.00
Total: $106.00
** A one time, non-refundable activiation fee ($10.00 for yearly payment or $25.00 for monthly payments) will be applied. Refunds vary by state.

How would you like to pay for this membership?


Membership Information (primary subscriber)


First Name*
Last Name*
Employer
Phone*
Birth Date* month day year
Gender*
Do you have a preferred dentist you like to visit?

Shipping address


Address*
Suite/Apt
Zip*
City*
State*

Billing Information Same as Member


First Name*
Last Name*
Phone*

Billing Address   Same as Mailing


Address*
Suite/Apt
Zip*
City*
State*

Referral information

If you were referred to New Dental Choice by your insurance agent, dentist, group or friend, please enter their referral source ID or name below. Please let us know how you heard about New Dental Choice.

Name or Code referred by

Membership Agreement

I understand the Plan Description of Services and Membership Agreement were provided prior to enrollment. I agree you will bill my credit card account automatically to renew my membership each year. I understand I may cancel my membership within 30 days and receive a full refund (less the activation fee). Refunds vary by state.

I have read the membership agreement and agree to its terms.*
Yes, I agree to the terms


(By selecting continue you will be redirected for secure checkout. If you are paying by credit card, secure checkout services are provided by Vantiv Payment Services. If you are paying by electronic bank draft, secure checkout services are provided by Cybersource.)