DR. GREEN DENTAL CARE PLAN SIGN UP
Name______________________________________ Date_______________
Name______________________________________________
Child_______________________________________________
Child_______________________________________________
PAYMENT OPTIONS
Individual One annual payment $339.00 |
Each Child One annual payment $249.00 |
SERVICES PROVIDED AT NO CHARGE
Dental Cleaning 2 per year |
Cavity detecting x-rays once per year |
X-rays in conjunction with emergency services |
Doctor exam 1-2 per year |
Fluoride treatments (under age 17)-2 per year |
ADDITIONAL PROCESSING FEE FOR THIS ONE PROCEDURE:
Complete x-rays (or panoramic radiographs)once every 5 years= $15.00 Processing fee additional to plan
TERMS AND CONDITIONS
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For dental treatment, all fees are due on the date of service.
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Plan members receive a 15% discount on all Dr. Green Dental Care Services. This includes emergency exams.
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Anything not listed above is extra but is subject to the discount.
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Panoramic radiographs are subject to a $15.00 Processing fee.
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Annual fee may be made by cash or check.
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All plan commitments are for one year. Pro-rated discounts do not apply for early withdrawal.
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Cannot be combined with another insurance plan (i.e. Delta etc.)
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May be used with company sponsored pre-tax and flex spending accounts.
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May be used after insurance maximum has been reached.
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Plan fees cannot be financed by dental third party financing plans (i.e. Care Credit).
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It is the patient’s responsibility to keep up with their preventative maintenance schedule and x-rays. Our usual reminders are done as a courtesy only. Unused preventative maintenance visits cannot be carried over to a subsequent year.
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The plan does not cover out of office general or specialty care.
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The plan does not cover outstanding balances incurred prior to enrollment.
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This is not an insurance product.
I understand all terms and conditions and agree to abide by them. All questions have been answered to my satisfaction.
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