Membership Sign Up Form

Please fill out the information below. We will contact you to discuss details and start dates.

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Thanks for Signing Up.

Membership Details 

Our memberships are designed to accommodate every type of patient out there. These plans include our standard of care for exams, cleanings, and x-rays for the year. This is what determines the price for each membership type to ensure we are taking care of you the best way we can. In addition to the preventative care the memberships also offer additional savings. Savings include a 10% discount to additional necessary treatment/services provided at our office as well as 5% discount to cosmetic in office services, some exclusions apply. See Exclusion paragraph for details.
5% subscription discount for adding a family member to your account. This offer is limited to one per person and the 5% will be applied to the total of both membership plan fees.

Membership Details
Date of first payment is the effective start date. You will need to provide a credit card for payment set up. The renewal date will be a consecutive 360 days from enrollment date. Before renewal you may opt out of membership for next year by stating no auto renewal during enrollment or completing a membership termination form.
Members are required to PAY IN FULL for additional services rendered at given appointment. Treatment fees are subject to change, but membership fees and discounts will remain intact for the given yearly membership. Memberships are not transferable or refundable. 
Memberships are a 12-month commitment. You may only receive money back if you decide within the first 30 consecutive days you would like to no longer participate. To cancel this membership before the yearly renewal date you may be responsible for a penalty fee. For late monthly payments there will be an additional $10 late fee, if there are two late monthly payments your membership will be terminated and reinstatement will be determined by doctor review. 


Exclusions
Exclusions to this membership are persons with dental insurance coverage. By dental necessity some cosmetic treatments, orthodontic treatments, implants, implant prostheses will be treated but otherwise excluded from the membership plan. Extensive or complicated treatment our doctors would refer to a specialist will be excluded from the membership plan. The membership plan may not be combined with any other discounts. Cosmetic or elective procedures performed by our providers may qualify for discount under certain circumstances. 

Consent
We are happy to offer a membership plan for your dental care needs. We want to provide you the care that you need whether you hold dental insurance or not. That is why we have put together these membership options. There are no copays or waiting periods dictated by insurance. Once you enroll your benefits start immediately. You will have access to all discounted procedure pricing with a treatment plan. 

 

Definitions 

Regular Periodic Exam: A full mouth exam that addresses your oral health. You will be provided with a treatment plan in accordance to what is recommended for your future treatment. Our standard of care is once every 6 months.

Prophylaxis Cleaning: A professional cleaning in accordance with your radiographs to better address areas of concern. This cleaning should be done once every 6 months according to our standard of care.

Periodontal Cleaning: A professional cleaning, basic periodontal therapy, in accordance with your radiographs to better address areas of concern and any 4+ mm pockets. This cleaning should be done once every 3-4 months according to our standard of care.

Routine X-rays: In accordance to our standard of care we require one panoramic x-ray every three years, one set of bitewings every year, and one full mouth x-rays every three years.

Emergency Exam: This type of exam focuses on one specific area of the mouth to address an area of concern that might occur outside the normal exams.

Oral Cancer Screening: An examination to look for signs of cancer or precancerous conditions in your mouth. The goal of oral cancer screening is to identify mouth cancer early, when there is a greater chance for a cure.