Desert Smart Choice

Alta Sky Dental

Peoria & 43rd Ave.

(623) 745-2868
Sierra Sky Dental

Indian School & 51st Ave.

(623) 233-0959
Desert Sky Dental

Thomas & 75th Ave.

(602) 833-1560
Mountain Sky Dental

7227 N Dreamy Draw Avenue

(602) 861-1245

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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