Dental Membership Plan Agreement – Healthy Gums

This Membership Plan is designed for patients without dental insurance who have healthy gums.

It is not dental insurance and cannot be combined with dental insurance or other discounts.

(If periodontal disease is present, a Periodontal Membership Plan is required.)

Annual Membership Benefits (per patient)

• 2 professional cleanings (healthy gum patients only)
• 1 comprehensive exam
• 1 periodic exam (during recall visit) with X-rays as needed (bitewings or periapicals)
• 1 full mouth series of X-rays (FMX, as clinically indicated — panoramic not included)
• 15% discount on all other dental procedures (applies to our standard fee schedule)
• Priority scheduling for emergency visits Terms & Conditions

Terms & Conditions

1. Membership is valid for 12 months from the date of purchase and must be renewed annually.
2. Membership fees are non-refundable. No refunds or prorating for relocation, change of providers, or unused benefits.
3. Membership is non-transferable to another person.
4. Eligibility requires completion of SRP therapy and dentist/hygienist recommendation for periodontal maintenance.
5. Cancellation/No-Show Policy: Appointments canceled or rescheduled within 48 hours, or missed without notice, will result in loss of that benefit.
6. Missed Benefits: Unused services do not roll over into the following year.
7. 15% discount cannot be combined with other promotional offers, coupons, or financing discounts. Discount applies only to services completed during active membership.
8. Membership fee must be paid in full at the time of enrollment.
9. Not valid with dental insurance, Medicaid, or any other dental coverage.
10. Additional exams or X-rays outside the listed services will receive the membership discount but are not included for free.
11. Our practice reserves the right to adjust fees or benefits annually. Terms may be updated at renewal.

Pricing (per year, per patient)

• Adults: $349
• Children (under 13): $299

Acknowledgement & Agreement

I understand and agree to the terms of this Healthy Gum Dental Membership Plan.