Our New Membership Enrollment

At Northern Westchester Dental Care, we understand that only some people have dental insurance available to them, so we have developed the NWDC Membership Plan for our families of patients without access to it. Keep in mind this is not dental insurance. Our membership plan allows you to make dental care a priority at an affordable cost!

First Name & Middle Initial *

Last Name*

Sex

MaleFemale

Address

City

State

Zip Code

Phone Number*

Opt-In to Receive Text Messages

Yes, I'd like to recdeive text messages**

Email *

Date of Birth*

Spouse's First Name & Middle Initial

Spouse's Last Name

Sex

MaleFemale

Spouse's Date of Birth

Enrollment Period (Month / Year - Month / Year)

Please List All Children you with to Enroll Name

Credit Card Type

Card Number

Expiration Date

Signature*

**By providing my phone number, I consent to receive SMS text messages from United States for appointment reminders, marketing messages, and general two-way communication. Msg frequency varies. Msg&data rates may apply. Reply HELP for support. Reply STOP to opt out. Read our Privacy Policy.

If you are having a DENTAL EMERGENCY call the office phone number directly – 914-245-3103.