CHOICE DENTAL MEMBERSHIP PROGRAM SIGNUPBronze - Individual (N100,000)₦100,000.00Bronze - Family (N200,000)₦200,000.00Silver - Individual (N150,000)₦150,000.00Silver - Family (N300,000)₦300,000.00Gold - Individual (N200,000)₦200,000.00Gold - Family (N400,000)₦400,000.00Platinum - Individual (N300,000)₦300,000.00Platinum - Family (N500,000)₦500,000.00Select Your Payment CycleBronze - IndividualSelect Your Payment CycleBronze - FamilySelect Your Payment CycleSilver - Individual Select Your Payment CycleSilver - FamilySelect Your Payment CycleGold - Individual Select Your Payment CycleGold - FamilySelect Your Payment CyclePlatinum - Individual Select Your Payment CyclePlatinum - Family Number Of Dependents 1 2 3 Number Of Dependents 1 2 3 Number Of Dependents 1 2 3 Number Of Dependents 1 2 3 Please Signup*First Name * First NameFirst Name can not be left blank.Please enter valid data.This first name is invalid. Please enter a valid first name.*Last Name * Last NameLast Name can not be left blank.Please enter valid data.This last name is invalid. Please enter a valid last name.*Username * UsernameUsername can not be left blank.Please enter valid data.This username is already registered, please choose another one.This username is invalid. Please enter a valid username.*Email Address * Email AddressEmail Address can not be left blank.Please enter valid email address.Please enter valid email address.This email is already registered, please choose another one.*Password * PasswordPassword can not be left blank.Please enter valid data.Please enter at least 6 characters.Strength: Very Weak*Phone Number * Phone NumberThis field can not be left blank.Please enter valid data.Please enter at least 11 characters.Please enter valid data.*GenderMaleFemalePlease select one.Please enter valid data.Done(Use Cropper to set image and use mouse scroller for zoom image.) ONLINE PAYMENTSWIFT PAYSelect how you want to pay Auto Debit Payment Manual PaymentPayment SummaryYour currently selected plan : , Plan Amount : Coupon Discount Amount : , Final Payable Amount: SubmitAlready have an account? Login