SIGN UP FOR MY SMILE DENTAL PLAN Office*Desert SkySierra SkyAlta SkyReferrerName* First Last Birth Date* Email* Phone*Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Annual membership is $99 per adult and $49 for each additional dependent under the age of 18.Number of Adults123456Number of DependentsSelect123456Total $0.00 Name of Additional AdultName of Additional AdultName of Additional AdultName of Additional AdultName of Additional AdultName of DependentName of DependentName of DependentName of DependentName of DependentName of DependentSignature*Consent* Your plan will automatically renew on your anniversary date each year unless cancelled 30 days in advance.