Membership in this plan includes 2 regular cleanings, 2 periodic exams and preventive x-rays per year. Limited/emergency exams are covered. Each membership includes 25% off any dental treatment such as root canals, fillings, crowns and bridges. Downtown Parker Dental Care Plan is for patients not covered by a dental insurance plan or dental discount card through Delta, Aetna or Cigna.

Invisalign and Sleep Apnea appliances are not included in the membership plan. However, a $500 credit may be applied to these treatments.

Maintaining your dental health requires the patient to make and keep their preventive appointments twice a year.

Patients may sign up with front office for this plan. You need to have a credit card we can keep on file or checks for each month. Membership is for 12 months – if patient decides to leave prior to 12 months the monthly fee is applicable and charged through the 12 month period.

Membership payments may be made in full saving $30+ per year. You may use CareCredit or Lending Club for the membership if you have an account. It is easy to apply at either:

• www.carecredit.com
• www.lendingclub.com/dental

MEMBERSHIP FEES AS FOLLOWS:

The patient understands the benefits,exclusions and requirements of the plan. You must remain in plan for a minimum of 12 months and have payment method on file with office. If permitted by law, if patient makes less than 12 months of membership fees it may result in being charged usual and customary fees for all services (including treatment already provided) and card may be charged remaining months’ fees in one full payment.

Fees for dental services are due and payable on the day treatment is rendered. You agree in joining this plan to pay any and all costs in collecting all charges, including but not limited to attorney fees and court costs. Credit cards not able to be charged or checks that are returned will result in patient being sent to collections for the remaining membership balance and any and all outstanding treatment balances. The collection agency will report this to credit bureau. Any credit card that becomes inactive or checking account that is closed will render the membership void if a new method of payment is not given to the office within 10 days of debit.

DOWNTOWN PARKER DENTAL CARE PLAN EXCLUSIONS

• Referral for treatment at specialist’s office
• Invisalign
• Clear Correct
• Traditional braces
• Sleep Apnea appliance
• Snore guard
• Nightguard
• Any products purchased at Downtown Parker Dental
• Teeth whitening
• Any treatment not deemed necessary by Dr. DiGiorgio
• Treatment covered under Workers’ Compensation
• Patient that becomes covered by traditional dental plan will render this plan void with no refunds
• Medications that are not normally prescribed in a dental office
• Loss or theft of bridges, dentures, sleep apnea appliance, snoreguard, ortho retainers
• Medical benefits for any treatment
• Treatment provided to patient at no charge by county or state.
• General anesthesia
• IV sedation
• Treatment that cannot be rendered due to patient health
• Non-compliance with recommended treatment plan
• This plan does not apply to patients with dental insurance
• Any specials Downtown Parker Dental is currently running with not be eligible for the discount of 25%.

The Downtown Parker Dental Care Plan is NOT a dental insurance policy. There are not claims filed nor is it a pre-paid dental plan under Colorado law. Patients must pay for all dental treatment and other than plan exclusions will receive 25% off dental treatment other than those treatments covered by membership plan. This an in-office plan and does not constitute paying an insurance premium. This is NOT DENTAL INSURANCE.

THE FOLLOWING PROCEDURES ARE EXAMPLES OF MONIES SAVED WITH DOWNTOWN PARKER DENTAL CARE PLAN:

I wish to join Downtown Parker Dental Care Plan

Patient Name               ______________________________(Please print)
Patient signature         ____________________________
Date                             _______________
Method of Payment     _________
Check or Credit Card #_________________Exp____Code____