Membership Agreement
DENTAL MEMBERSHIP PROGRAM AGREEMENT
Our membership program is designed to provide a simple, budget-friendly option resulting in greater access to regular and consistent quality dental care. This is an alternative to conventional dental “insurance”.
Plan options are simple; The monthly and/or annual membership fee per plan are as follows:
Child Member Monthly $30.00, annually $353, reflects savings of $132 plus 6% discount
Adult Member Monthly $36.00, annually $425, reflects savings of $145 plus 6% discount
Adult Member Monthly $47.00 (3 Hygiene visits per year) annually $555, savings of $150 plus discount
Perio Member Monthly $54.00 or Annually $649, reflects savings of $203 plus 6% discount
The monthly and/or annual membership fee for the Child and Adult plan options include: 2 cleanings, 1 set of bitewing (cavity finding) x-rays, 2 periodic exams, oral cancer screening, oral hygiene instructions, 2 fluoride treatment, 1 emergency exam. A discount of 6% is extended on dental services with no limit.
The monthly and/or annual membership fee for the Perio options include: 2 cleanings,2 perio maintenance visits, 1 set of bitewings, 2 periodic exams, oral cancer screening, oral hygiene instructions, 2 fluoride treatments, 1 emergency exam. A discount of 6% is extended on dental services with no dollar limit. Services must be paid in full the day the treatment is started to receive the discount. Retail items (i.e. toothbrushes, at-home whitening products, ZOOM, periodontal products, etc.), medications, drugs, dermal fillers, botox, medical services including sedation (nitrous, IV sedation, anesthesiologist), and orthodontics are not discounted.
Benefits are only available to you by Dansville or Bath Dental Professionals, LLP. This program is a discount plan by definition: a program that intends to offer discounts on health care services and is not insurance. This cannot be used in conjunction with conventional dental “insurance”.
"Year" and "Annual" refer to the 12-month period beginning the 1st of the month you enroll.
Per 12 months services do not roll over to the next year and are not transferable. (Unless we cancel your appointment for unusual circumstances. For example, your hygienist called in sick, we have a power outage, we closed the office for staff training, etc.) Bad weather is not considered an office cancellation.
Monthly payments are paid through automated credit card or debit card billing set up by the patient through the third-party secure web site. We do not see or store your credit card information. Annual payment may also be made by cash or check in our office in advance of the due date. There will be no monthly billing.
Late payments, or credit card or debit card payments that fail to clear will result in you being cancelled from the program. You may discontinue the program at any time. Your agreement will automatically renew annually for your convenience. You will automatically be included in any free upgrades we make to the program. The membership fee may be adjusted without notice as necessary to stay consistent with practice standard fees. Membership discounts and cost savings will remain consistent. .If you discontinue during an incomplete agreement year, any discounts received during that year will be reversed and due immediately. For example, if you enroll in the plan, receive hygiene services, and/or have dental work completed at discounted rates, and then drop the program in the same year, the discounts received during the current incomplete term will be reversed. This is to prevent obvious abuse of the intended purpose of the program. https://dansville.myplan.dental
By signing below, I am indicating that I have read and understood and agree to the terms and conditions as outlined above.
Patient Signature_____________________________________ Date___________________
Staff member signature ________________________________ Date _________________