In-Office Dental Benefits - Mansell Dentistry

Enroll below! If you have any questions please call us at (480) 757-0007. We look forward to serving you.

List of Members to Enroll*
First Name Last Name Relationship DOB

(use the + sign on the right to add rows for additional members)
Marketing
Consent*
I agree to the terms and conditions.*
This is an annual reduced fee dental plan that allows individuals and families to receive quality dental care. Dr. Mansell offers a percentage off the office’s usual, customary and reasonable (UCR) fees. This is not an insurance plan, no claims are filed, and no payments are made to any other healthcare providers. This plan may not be combined with any other offers, discounts, insurance, discount plans or advertisements.
Once the annual fee is paid, you will be entitled to the dental benefit membership program for 12 consecutive months. You have the right to cancel at any time, by submitting a written request however, this plan is non-refundable.
Electronic signature*
First Last
By typing your name here, you are signing this enrollment electronically. You agree your electronic signature is the legal equivalent of your manual signature.
Signed on: 10/13/2019

First Name	Last Name	Relationship	DOB