Use this form to sign up for SDC's SmileRider program in which participating dentists agree to
offer SDC members a 15% discount on cosmetic and non-covered dental services and procedures.
By participating in this program, your office will be highlighted in our directory with our SmileRider icon.

First Name:	*
Last Name:	*
Email Address:	*
License Number:	*
Specialty:
Practice Name:	*
Address:	*
City:	*
State / Zip:	* / *

By entering my initials in the box below, I certify that I am an authorized representative of the company identified on this form and that any information submitted is accurate and current.

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