Download LAST NAME________________________FIRST__________

LAST NAME________________________FIRST_______________________ MI_______ D.O.B______________
HOME ADDRESS_____________________________________________________________________________
STREET
CITY
STATE
ZIP
HOME PHONE__________________________ CELL _________________________WORK _________________
List Covered Dependants:
(Eligible dependants include only spouses, children under the age of 18 and full-time students 25 and younger.
Proof of student status required.)
Name
Birth Date
Relationship
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Collins Dental Plan - Total Amount Due $______________
($338 for first member plus $256 for each additional dependant)
Please read and sign below:
Collins Dental Plan offers significant discounts on dental services. I understand the benefits, limitations
exclusions and requirements of this plan and agree to the following: Fee for dental services is due when
rendered. Fees for prosthodontic (dentures) and cast restorations (crowns, inlays, onlays, veneers) are due at
the preparation/impression visit. Use of Care Credit for payment will result in a service fee. If you choose not
to pay at the time of service you will billed our usual and customary fees for such services. VIP patients may
still use their additional discount. Member benefits may not be used with any other offers. Using CDP, our office
offers significant savings to patients in regards to dental services. Furthermore, I understand this is not dental insurance
and this is not discount medical plan as defined in FL statute 636.202. I understand the benefits, limitations, exclusions,
and requirements and agree to the following:
 Fees for dental services are due when rendered; and
 Fees for prosthodontic (dentures) and cast restorations (crowns, in-lays, on-lays, veneers) are due at the
preparation/impression visit.
Signature______________________________________________ Date ___________________
Renewal Date: __________________
5739 Canton Cove, Winter Spring, FL 32708
Phone: 407-699-9831
Fax: 407-699-9896
Helping keep Dental Costs Low - Helping Keep Private Practice Private
SAVINGS PLAN LIMITATIONS & EXCLUSIONS

Dentist provides any medications not regularly stocked by our office.
● Any procedure that is considered to be experimental.
● Hospitalization for any procedures.
● Services unable to be completed due to the patient’s medical health, mental health, or other unhealthy status.
● Conditions or services under Worker’s Compensation or Employer’s Liability laws.
● Congenital malformations other than congenital anomaly of tooth/teeth from birth.
● Any diagnosis or treatment of myofacial pain dysfunction syndrome.
● Any whitening services are complimentary and included once annually and nontransferable.
● Any alterations, restorations, or treatments of the temporomandibular joint.
● Any procedures for full mouth rehabilitation requiring appliances or restorations.
● Any services provided for free by a county, government, municipality, or other agency.
● Any appliances, diagnosis or treatments conducted by a referral made to another dentist or specialist outside of
the providers of our office in order to complete treatments in connection with any dental procedure in this
office.
● Patients cannot use their own dental insurance benefits or other dental coverage in conjunction with any part of
CDP.
● Services are nontransferable.
● Any missed appointments or cancellations not made within 48 hours of the appointment may be charged a 25%
fee of the services that was to be rendered.
● All payments shall be interest free upon credit approval during months 3, 6, and 12.
● Payment plans can be made upon request and depend on the total amount due and type of dental procedure.
Any patients using a payment plan or interest free payments shall have their payments customized to their
financial needs.
● All fees are due in full at the time services are rendered.
● No refunds.
● Family members within the same account shall have the same anniversary date regardless of agreement date.
● Periodontal disease patients shall only receive a periodontal maintenance cleaning provided two times a year.
However, this is not sufficient cleaning for a patient with periodontal disease. The cost for such cleaning shall be
paid at the time of service rendered. If you pay in full for the periodontal disease cleaning in full at the time the
service is rendered a discount may be offered on the next cleaning.
5739 Canton Cove, Winter Spring, FL 32708
Phone: 407-699-9831
Fax: 407-699-9896
Helping keep Dental Costs Low - Helping Keep Private Practice Private