(Affordable Dental Plans)
Below, and FAX to (484) 322-9681
Doctor Registration Form
ٱ YES, I want to receive the AFFDENT private dental plan program. I want to help my patients who do
not have dental benefits receive basic dental care and at the same time, personally earn a monthly
residual income. I understand that by registering with the AFFDENT program I will be assigned a
personal representative who will be available to help me and my dental staff get started and to
answer any questions we may have.
Upon registration I understand I will receive a starter kit that will include:
· A Standard Operational Procedures Office Manual and Marketing Strategies.
· Master copies of Patient Membership Forms and Dental Specialists Participation Forms.
· 100 AFFDENT patient brochures and a desk display acrylic brochure holder.
· Contact information for your assigned AFFDENT representative who will provide you with life-
time consulting in marketing, promoting and maintaining this program on your office website, with
your existing patient base, with local small businesses and surrounding neighborhood
demographics.
Please complete the following application information:
Doctor’s Name: ______________________________________________________
Office Address: _______________________________________________________
City: _______________________________ State: _______ Zip Code: ___________
Office Phone Number: _____________________ Fax Number: __________________
E-mail Address: _______________________________________________________
The AFFDENT private dental plan program starter kit is $197. I choose to pay for the kit via:
ٱTelephone: 913-631-2677. Office hours are 7:00 a.m. to 5:00 p.m. Mondays through Thursdays and
9:00 a.m. to 2:00 p.m. on Fridays CST. This phone number will ring into Dr. Kelly Bridenstine’s dental
office, Perfect Smiles Dental Care. You may leave your name, address, phone number and credit
card information with the office administrator. If the office is closed when you call, please leave
your name and phone number on the answering machine and we will call you back ASAP.
ٱMail: Please mail a check or credit card information along with this completed registration form to:
AFFDENT, Inc.
8308 Allman Road
Lenexa, Kansas 66219
ٱCredit Card: Please mail credit card information along with this completed registration form to the
above listed AFFDENT, Inc address or fax this completed registration form to: 1-484-322-9681.
ٱVISA ٱ Master Card ٱ American Express ٱ Discover
Credit Card Number: ___________________________ Expiration Date: __________
SIGNATURE: ______________________________________________
