Northpointe Patient Forms* indicates a required field

Perio Maintenance Membership Form

"*" indicates required fields

Dental Membership Plan Agreement – SRP / Periodontal Therapy Patients

This Membership Plan is designed for patients without dental insurance who have completed initial periodontal therapy (Scaling and Root Planing).

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

MM slash DD slash YYYY

Annual Membership Benefits (per patient)

  • 3 periodontal maintenance visits (following completion of SRP)
  • 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)

  • SRP Maintenance Plan: $599 (covers 3 periodontal maintenance visits + exams/X-rays)

Acknowledgement & Agreement

I understand and agree to the terms of this SRP / Periodontal Therapy Maintenance Dental Membership Plan.

Clear Signature
MM slash DD slash YYYY
This field is for validation purposes and should be left unchanged.