Dental Plan Application

Dental Membership
Upon application submission, Dental memberships will be processed automatically. Payment information will be collected on the next screen.
Dental Memberships are as follows ($50-lifetime activation fee paid to illumatrac):

$21 per month
for Regular Membership

$28 per month
for a Perio Membership (includes 3-4 Perio cleanings per year)
Tell us who wants to enroll:*
Including yourself, please list all who need a dental membership. Use Regular, Perio or Child for the membership type field.
Use the ⊕ button to add more than one.
First Name Last Name Date of Birth Membership Type

Payment Information
Dental memberships will be processed automatically using the payment information submitted below.

This website and application form is secure and your payment information will be encrypted using AES-256 bank/military grade database storage encryption.
Bank Name*
Routing Number*
Checking Account Number*

Thank you for taking the time to apply for a Dental Plan with ISG!

By pressing submit, you give ISG permission to process your application and monthly payment using the information provided. If approved, your Dental membership will start the 1st of the next month after your enrollment date. If there is a problem with your application, an ISG representative will be in contact.
Phone
This field is for validation purposes and should be left unchanged.

Apply for an ISG Dental Membership today!