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Welcome To Dentex Membership Sign Up
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| Please Enter Member Information! |
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| Membership: |
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| Last Name: |
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| First Name: |
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| Middle Initial: |
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| Date Of Birth: |
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| Gender: |
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| Email: |
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Referred by:
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I hereby make application to enroll in Dentex Dental Plan, Inc for a minimum of one year.
I hold Dentex blameless for any negligence on the part of the
Participating provider and agree to discuss all fees with the provider before I receive services. Dentex may terminate this agreement without cause by sending a notice of termination to the above address.
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