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1

Responsible Party

2

3

Responsible Party Information

Please enter the name, mobile and address for the responsible party that will be billed for this account.

First name

Middle initial optional

Last name

Account holder’s email address

Mobile Phone

I agree to receive text message alerts from Avondale Dental Group

Address

Suite/apt no

Address 2

City

State

ZIP code

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After creating your account, you'll receive an email to set your password.

Avondale Dental Group

Location

1683 E. Miles Ave.

Hayden Lake, ID 83835

Phone

208-772-4066

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