Fill-up the form to become our esteemed panel dentist

(We are empaneling only 9 dentists for a particular pincode area so, Hurry Up...!)
Empanelment of Dentist/Dental Clinic with Secure Dental Care Plan is voluntary and without any "Joining Fee"
Only Documentation/Legal/Portal Maintenance Fee applicable

Fields marked with * are compulsory
 Male     Female
 BDS      MDS
Pincode* :
Mobile No* :
(for office use only. All communications will be made on this number)
Clinic Phone No. :

Photo size should not exceed 300 KB

Treatment ChargesNormal (without discount) Rate Card of routine dental procedures on which panel dentist agree to provide discount.
Write NA if you do not want to provide any discount on any particular procedure. Mention any other procedure & charges where you wish to provide discount. To keep uniformity, we recommend (not binding) quoting scaling charges as Rs. 600, 400, 200 respectively for 1st, 2nd, 3rd sitting.

Keep a copy of this filled-up Rate Card with you for reference.
{Consultation: Free, Discount on Scaling & IOPA: 50% on normal charges, Discount on other Treatment: up-to 20% on normal charges}

Note: Treatment charges are not publicly visible on the website. They can be viewed only by the panel dentist and person registered with Secure Dental Care Plans (after entering the registration number)

1. Check-up & Consultation* 27. Complete Denture: Imported*
2. Scaling- 1st sitting (app.20min.)* 28. Veneer: Composite*
Scaling- 2nd sitting (app.15min.)* 29 Veneer: Porcelain*
Scaling- 3rd sitting onwards (app.10min)* 30. Complete Denture: FlexibleM*
3. Dental X-ray (IOPA)* 31. Gingivectomy: Single tooth*
4. GIC Filling: Adult* 32. Gingivectomy: Per quadrant*
GIC Filling: Pediatric* 33. Flap Surgery: Per quadrant
Bone Graft material charges extra*
5. LC Composite: Class II* 34. Flap Surgery: Full mouth
Bone Graft material charges extra*
6. LC Composite: Class I,III,IV,V* 35 Extraction: Mobile Tooth*
7. Silver Filling: Class I* 36. Extraction: Firm Tooth*
8. Silver Filling: Class II* 37. Extraction: Complicated*
9. Pit & Fissure Sealent* 38. Extraction: Root Piece*
10. Crown: Metal* 39. Surgical Extraction Of Bony
Impacted Third Molar*
11. Crown: Metal-Acrylic facing* 40. Apisectomy (RCT extra)*
12. Crown: PFM* 41. Cyst Enucleation (RCT extra)*
13. Crown: Full Ceramic* 42. Temporary Filling*
14. Crown: Zirconia* 43. Recementation: Single tooth*
15. Crown: Zirconia (LAVA)* 44. Orthodontic T/t: Removable
(U & L Arch)*
16. Root Canal Treatment: Anterior* 45. Orthodontic T/t: Fixed*
17. Root Canal Treatment: Posterior* 46. Implant- Single with prosthesis*
18. Root Canal Treatment: Pediatric* 47. Post-Core: Pre-fabricated-Metal
(RCT extra)*
19. Removal Partial Denture: Single* 48. Post-Core: Fiber Post (FRC)
(RCT extra)*
20. RPD: Additional Tooth* 49. Post-Core: Custom made
(RCT extra)*
21. Cast Partial Denture: Single* 50. Bleaching: First Sitting*
22. CPD: Additional Tooth* Bleaching: Extra Sitting*
23. RPD: Flexible* 51.
24. RPD: Flexible- Additional Tooth* 52.
25. Complete Denture: Regular* 53.
26. Complete Denture: Imported* 54.
 I declare that all the above mentioned details are true to the best of my knowledge.
 I have read, fully understood the above mentioned terms and I agree to abide by the same
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