Dental Wellness Program Enrollment Form

Program Information

The Dental Wellness Program is a discounted membership program that allows patients to receive quality dental care at reduced prices. This discount program is NOT a dental insurance policy.

This program is offered to patients who do not have dental insurance.

Patients must pay for services in full at the time services are provided and will immediately receive a 20% discount on all services, including today's visit, during the first year when recommended recare visits are maintained. The discount is 22% during the second year and 25% during the third year and beyond.

Recommended recares are based on ADA recommendations and include, but are not limited to, periodic exams, necessary digital radiographs (x-rays) for diagnostic purposes, and recommended recare intervals. Recare visits must be no more than 60 days from the recommended interval.

Agreement

I understand the benefits, limitations, exclusions, and requirements of this program.

I will maintain the recommended recare to receive my discount.

I am aware the discount is based off Fox Family Dental LLC's full fees.

I understand that failure to comply will result in the discount program being void and full fees will be due at the time of service.

Limitations & Exclusions

I acknowledge: Dental products (products are sold in office at cost)

I acknowledge: Referral to specialists

I acknowledge: This program will not be offered in conjunction with any other discount provided by our office

I acknowledge: The program will be voided for anyone who becomes covered with dental insurance Patient Inform

Patient Information

Patient Name (printed):

Date:

Signature of Enrollee:

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