Welcome to our new Healthy Smiles Dental Membership Plan!!
We know that for patients of ours without dental insurance, dental care can be costly. That’s why we created Healthy Smiles Dental Membership Plan!It’s a brand-new way to keep your smile bright and healthy while saving money!
Unlike dental insurance, Healthy Smiles Dental MembershipPlanhas no deductibles, no maximums, no qualifications, pre-existing conditions, pre-determinations, or any of the other red tape that can make dental insurance so confusing and annoying. That’s because Healthy Smiles Dental Membership Planis not dental insurance – it is a Membership Plan that we are bringing right to you without any third-party interference!
With an extremely affordable membership fee, Healthy Smiles Dental Membership Plan members get:
- Two regular dental examinations per year
- Two preventive cleanings per year
- Any x-rays associated with your preventive visits
- Oral cancer screening, blood pressure reading, oral hygiene instruction, TMJ screening, and many other services
- Two emergency visits per year with any necessary x-rays
- Two fluoride treatments per year
It’s all included in the plan at no extra charge!
Plus, if you do need more extensive dental treatment such as fillings, crowns, bridges, dentures, implants, gum treatments, or even cosmetic dentistry such as whitening and porcelain veneers – you get a 20% savings from our regular fee!! Best of all, you won’t have to worry about annoying maximums or deductibles. You will receive all of the dental treatment you need without any insurance company interference!
There really is nothing else like a Healthy Smiles Dental Membership Plan! It will keep you smiling AND saving.
SINGLE ADULT MEMBERSHIP
ADDITIONAL ADULT MEMBERSHIP
CHILD MEMBERSHIP UNDER 16YEARS OLD
COVERAGE IS IN EFFECT FOR TWELVE ROLLING MONTHS FROM SIGNUP DATE. COVERAGE BEGINS WHEN MEMBERSHIP HAS BEN PAID IN FULL. MEMBERS WILL BE NOTIFIED ONE MONTH PRIOR TO MEMBERSHIP RENEWAL. APPOINTMENT TIMES ARE LIMITED AND IT IS THE RESPONSIBILITY OF THE MEMBER TO SCHEDULE APPROPRIATE VISITS.
DR. LEVINE AND HER TEAM HAVE REVIEWED MY HEALTHY SMILES MEMBERSHIP PLAN WITH ME. I HAVE HAD THE OPPORTUNITY TO ASK QUESTIONS AND I FULLY UNDERSTAND MY MEMBERSHIP. I UNDERSTAND THAT THIS IS NOT AN INSURANCE POLICY AND THERE WILL BE NO THIRD-PARTY BILLING. I ALSO UNDERSTAND THAT PAYMENT IS DUE AT THE TIME OF SERVICE UNLESS OTHER FINANCIAL ARRANGEMENTS HAVE BEEN MADE PRIOR TO THE APPOINTMENT DATE.
I AUTHORIZE DR MEREDITH LEVINE TO RUN MY CREDIT CARD IN THE AMOUNT OF $________ FOR MY HEALTHY SMILE MEMBERSHIP PLAN. I ALSO UNDERSTAND THAT BY ENROLLING IN THE PLAN MY MEMBERSHIP WILL AUTO RENEW TEN DAYS PRIOR TO THE RENEWAL DATE BELOW.
I UNDERSTAND THAT IF I WISH TO DISCONTINUE MY MEMBERSHIP. I WILL NEED TO PROVIDE IN WRITING A SIGNED STATEMENT WITHIN THIRTY DAYS OF MY RENEWAL DATE. MY MEMBERSHIP IS NON-TRANSFERABLE.
I UNDERSTAND THAT THERE WILL BE NO REFUNDS PROVIDED FOR ANY UNUSED BENEFITS OR CREDITS FOR MISSED CLEANINGS, XRAYS OR EXAMS THAT ARE INCLUDED IN MY MEMBERSHIP PLAN.
Sample treatment plan:
|Usual & Customary Fee||Membership fee|
|2 surface composite fill(tooth colored)||$320||$256|
|1 surface composite fill||$250||$200|