Payment Form

Complete Your Membership Enrollment

Please take a moment to fill out the information below so that we can best serve you on your journey with Dental Collective! We can't wait to work with you.

Step 1: Confirm Your Plan Selection

* Required Field

Monthly Memberships

Solo Practice $99 / month

Multi-location $169 / month

Enterprise Groups $499 / month

Annual Memberships - Save 15%!

Solo Practice $999 / year

Multi-location $1,699 / year

Enterprise Groups $5,100 / year

Promo Code

If you have a promo code, please enter it below. The promo will be applied on the next screen.

Apply Promo

Step 2: Contact Information

* Required Field

Doctor Name *

Please enter your full name.

Doctor Email *

Please put your primary contact email.

Step 3: Practice Information

* Required Field

Practice Name *

Please enter the full legal name of your practice.

Office Manager/Supply Manager Name *

If you have an office manager or supply manager, please input their name here.

How many locations does your practice have? *

Quantity (1,2,3,etc.)

Practice Email

If you have a general practice email, please input that below.

Practice Phone Number *

If you have a general practice phone number, please input that below.

Street Address*

Please input the full street address for your practice. If you have multiple locations, please only put the primary business address.

City *

State/Province *

Zip/Postal Code *

Country *

Final Step: Enter Your Payment Information

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Have Questions?

Give us a call and we'll be glad to help!

(781) 701-6707