My Smile Plan Signup

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

SIGN UP FOR MY SMILE DENTAL PLAN

Office*
Referrer
Name*
First Last
Birth Date*
Email*
Phone*
Address*
Street Address City State ZIP Code
Annual membership is $99 per adult and $49 for each additional dependent under the age of 18.
Number of Adults
Number of Dependents
Total
$0.00
Name of Additional Adult
Name of Additional Adult
Name of Additional Adult
Name of Additional Adult
Name of Additional Adult
Name of Dependent
Name of Dependent
Name of Dependent
Name of Dependent
Name of Dependent
Name of Dependent
Signature*
Consent*
- Your plan will automatically renew on your anniversary date each year unless cancelled 30 days in advance.

Easy Financing - Click Here!

ES