Download a printable copy of our Savings Plan

SAVINGS PLAN
PATIENT REGISTRATION
LAST NAME: ________________________________ FIRST NAME: __________________________________ MI: _________
ADDRESS: ___________________________________________________ CITY, STATE, ZIP: ___________________________
PHONE: (_______) _________-______________ SECONDARY PHONE: (_______) __________-______________
DOB: ________/________/________
BILLING
PERSON RESPONSIBLE FOR BILL (ONLY COMPLETE IF DIFFERENT FROM PATIENT)
RELATIONSHIP TO PATIENT: (CHECK ONE): ( ) SELF ( ) SPOUSE ( ) PARENT
NAME: ________________________________________________________________
DOB: ________/________/________
ADDRESS: ____________________________________________________ CITY, STATE, ZIP: ________________________
PHONE: (_______) _________-______________ SOCIAL SECURITY #: _______ - _______ - _________
LIST ANY ADDITIONAL DEPENDENTS FOR PLAN:
NAME
DOB
RELATIONSHIP
TOTAL DUE $_________________
METHOD OF PAYMENT (CHECK ONE): ( ) CASH ( ) CHECK ( ) DEBIT CARD
( ) MASTERCARD ( ) VISA ( ) AMERICAN EXPRESS ( ) DISCOVER ( ) CARE CREDIT
PLEASE READ DISCLAIMER AND SIGN BELOW:
Using our Savings Plan in our office offers significant savings to our patients on dental services rendered. Furthermore, I understand
the benefits, limitations, exclusions, and requirements of this plan and agree to the following:
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Fees for dental services are due, in full, when rendered
Fees for prosthodontic (dentures) and cast restorations (crowns, in-lays, on-lays, veneers) are due at the
preparation/impression visit.
If I, __________________ choose not to pay at the time of service, I shall be charged and pay the customary fees for such services. I
acknowledge that I am financially responsible for payment, in full, at time of services in order to take advantage of the savings being
offered on my membership. If I do not pay, in full, at time of services I understand that I will be required to pay the customary fees
for the services delivered regardless of my membership status.
SIGNATURE: ______________________________________________________________ DATE: _________________________
Explanation of Benefits
Our plan is an annual dental savings plan for families and individuals that allows all members to receive
quality dental services at greatly reduced prices. Unlike conventional insurance plans, with our plan there
are no deductibles, no yearly maximums, and no waiting periods to begin treatment. Benefits and
savings begin immediately upon registration.
Our Benefits/Savings include:
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INCLUDED Teeth cleaning benefits (two per year)
INCLUDED Complete annual dental exam (two per year)
INCLUDED All x-rays needed to complete annual exam (Panoramic and Bitewing x-rays)
INCLUDED Teeth whitening (Opalescence Go4 Pack)
INCLUDED Emergency Exam (when definitive treatment is completed the same day as diagnosisa value of $50)
A 20% savings on bleach trays and in-office whitening
A 20% savings on periodontal treatment
A 15% savings on general and restorative procedures
A 10% savings on major procedures
A 10% savings on implants and implant restorations
A 10% savings on all fluoride products and sealants
The fee paid is for included services and represents a courtesy accounting adjustment for a value of
$555.00. The initial fee is $349.00 for one individual and only $299.00 for each additional family
member, which represents an additional savings of $50.00. Eligible family members include spouse
and dependent children between age 14-19 (up to age 23 if dependent child is a full-time student). Fees
are due and payable when services are rendered and are non-refundable when services have been
provided. Savings duration is for one year from registration date. All patient portions for services
received are due at time of services in order to receive savings. Interest-free payment plans of a 6
month duration are available upon request with approved credit. Repayment duration is based on
service totals and procedural type. If you choose to use a repayment plan, your savings and interest free
payment options will be customized for your repayment needs. A missed appointment fee of $30 (or
25% of total treatment for treatment over $1000) will be charged for all missed dental appointments.
Please notify our office at least 48 hours in advance if you must change your reserved appointment.
Fees charged are not membership fees and all fees paid are for provided services only. Terms subject
to change.
SAVINGS PLAN LIMITATIONS & EXCLUSIONS
EXCLUDED FROM OUR SAVINGS PLAN:
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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 patients’ 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 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.
The fee paid for our Waldron Dentistry Savings Plan is for included services and represents a courtesy
accounting adjustment for payment, in full, at the time of service.
There are no refunds on your Waldron Dentistry Savings Plan fee.
All payment for services are due in full at time of services in order to receive savings
Waldron Dentistry Savings Plan fees are not transferrable
Waldron Dentistry Savings Plan patients cannot use their own dental insurance benefits or other dental coverage
in conjunction with any part of the Waldron Dentistry Savings Plan
Any unused services within the Waldron Dentistry Savings Plan are nontransferable to other patients regardless
of the service.
Any missed appointments or cancellations not made within 48 hours of the appointment may be charged a $30
fee. Missed appointments or cancellations not made within 48 hours for treatment over $1000 will be charged
25% of the services that were to be rendered.
If Care Credit is used for financing treatment, all payments terms will be made to Care Credit and will be offered
repayment over 6 months where approved. The initial fee is $369.00 for one individual and only $319.00 for
each additional family member. Care Credit CANNOT be used for in office monthly payments. If Care Credit is
used for treatment, discounts will be reduced to 10% savings on periodontal treatment, 5% savings on general
and restorative procedures, and 0% savings on major procedures, implants, implant restorations, and over the
counter products.
Payment plans can be made upon request and depend on the total amount due and type of dental procedure.
Patients using a payment plan option will have their savings offered, on our program, customized to their
financial needs. An initial down payment of $80 is required for the first month and $29/month for 11 months will
be automatically charged to a card place on file.
If you have Periodontal Disease, a Periodontal Maintenance will be performed as a ‘simple’ cleaning will not be
sufficient for your oral health care needs. Should you need more than two Periodontal Maintenance visits within a
year, the plan benefits will apply to the first and third Periodontal Maintenance visits. Each additional
Periodontal Maintenance visit will have a 20% discount (or 10% for Care Credit users).
Procedures and products not eligible for discounts include: Botox, Juvederm, Nitrous, In-Office Prescriptions,
Sedation, Waterpiks