Click to Call Us We’re Sorry To See You Go! If you wish to cancel your In-office Dental Membership Plan, please fill out the form below or give us a call at (631) 752-2929. Full Name* Date of Birth* Cell Phone*Home PhoneWork PhoneEmail* Insurance PlanIs this Cancelation for Monthly Recurring Payments or Cancelation of your whole Dental Membership Plan?* I wish to cancel my whole Dental Membership Plan I wish to cancel my Monthly Recurring Payments Please select who is Canceling today.*If you are canceling for multiple family members, then please check off a box for them and you will be prompted to enter their info. Self Spouse or other Adult Adult 2 Child 1 Child 2 Child 3 Spouse/Adult Full Name* Spouse/Adult Date of Birth* Relationship* Adult 2 Full Name* Adult 2 Date of Birth* Relationship* Child 1 Full Name* Child 1 Date of Birth* Relationship* Child 2 Full Name* Child 2 Date of Birth* Relationship* Child 3 Full Name* Child 3 Date of Birth* Relationship* Δ