Superior Dental Care Secure Form
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.
SIGN UP FOR SMILERIDER
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.
Initials: