Enroll Now

You are on a secure webpage.

secure area CreditCardLogos-full



Applicant’s Information

How did you hear about us?
Valid Email Address
Comfirm Email Address*
Last Name
First Name
Date of Birth
Home Address include APT#
Zip Code
Home Phone
Cell Phone
Dependants Names & Dates of Birth (D.O.B)
1)D.O.B. 2)D.O.B.
3)D.O.B. 4)D.O.B.
5)D.O.B. 6)D.O.B.
7)D.O.B. 8)D.O.B.
Payment Information
How will you be paying?
Credit Card #
Expiration Date
Name on card

Complete only for Bank Draft only* (Initial draft begins immediately and thereafter, on the 15th of each month)

Routing *
Account# *
Check# *
Driver’s License#

Continue Payment Information

How will you be paying? Monthlyor Annually Semi-Annual
Select Monthly Amount
Select Semi-Annual Amount
Select Annual

save 5%
Total Submitted Add $25.00 to Monthly or Annual amounts

Signature is confirmed by checking “I accept”
Please check here “I accept” to sign and authorize.

Then press submit below.
Thank you for your business!

I wish to enroll with American Dental Care Partners, Inc. I understand this is an annual agreement and that all necessary dental services will be provided as described in the Member Fee Schedule. I have received a copy of the Member Fee Schedule. This plan will automatically renew every year unless otherwise notified and payment on file will be applied. If paying for 6 months, filling out this application authorizes American Dental Care Partners, Inc. to automatically debit the memberís remaining 6 months of the one-year agreement from the account used to pay for the first 6 months. An annual service fee will apply, not to exceed $12.00. Returned checks will result in a $30 fee. A late fee will be assessed, not to exceed $4.00 for each month the membership is past due. If the member cancels membership with American Dental Care Partners, Inc. within the first 30 days after the effective date of enrollment in the plan, the member shall receive a reimbursement of all periodic charges upon return of the discount card to American Dental Care Partners, Inc. Cancellations by telephone will not be accepted. The cancellation must be in writing to:

American Dental Care Partners, Inc., 11221 Katy Freeway, Suite 209, Houston, TX 77079. Or fax 713-784-6928.

Note* American Dental Care Partners, Inc. does not share and sell your email or any personal information.

The annual service fee, the returned check fee and the late fee do not apply to FL residents.

Secure Transaction

DISCLOSURE: This plan is NOT insurance. The plan provides discounts at certain health care providers for medical services. The plan does not make payments directly to the providers of medical services. The plan member is obligated to pay for all health care services but will receive a discount from those health care providers who have contracted with the discount plan organization.
© 1989-2015 American Dental Care Partners. Inc. All Rights Reserved.