Desert Smart Choice

Opening Hours: Mon - Tue : 6.00 am - 10.00 pm, Sunday Closed

Alta Sky Dental

Peoria & 43rd Ave.

(623) 374-3714
Sierra Sky Dental

Indian School & 51st Ave.

(623) 849-1000
Desert Sky Dental

Thomas & 75th Ave.

(602) 535-2682

Name
First Last
Date of Birth
Email
Phone
Address
Street Address City ZIP Code
List those on plan
Spouse Name
Date of Birth
Child Name
Date of Birth
Child Name
Date of Birth
Child Name
Date of Birth
Child Name
Date of Birth
Child Name
Date of Birth
Other Name
Date of Birth
Other Name
Date of Birth
Marital Status
Gender
Employer Name
Employer Phone
Plan Options Annual Admin Fee Annual Fee Total Due

Individual Plan $20 $100 $120

2 Person Plan $20 $150 $170

Family Plan $20 $200 $220
Please Indicate Your Plan Selection
Signature
Date

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