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I understand the benefits, limitations, exclusions and requirements of the Plan and I agree to the following: I will remain in the plan and pay membership fees for the full duration of my plan. Payment of less than the plans duration membership fees may result in my being charged usual and customary fees for all services (including those already provided) and my being charged remaining months’ fees in lump sum. Fees for dental services are due as services are rendered. Fees for prosthodontic and cast restoration services are due at the preparation/impression visit. Failure to comply may result in my being charged usual and customary fees for such services. I agree to pay any and all costs in collecting all charges. Including but not limited to attorney fees and court costs. Coverage must be continuous. Missing monthly payments must be made up for interrupted coverage. Last month fees are not refundable.

I understand that I have 30 days from the initiation of this contract to cancel my membership without cause, and receive a full refund. After 30 days I will assume the full plans term.

DENTAL LIMITATIONS AND EXCLUSIONS
1)Demonstrated non-compliance with recommended course of treatment. 2) Services which in the opinion of the attending dentist are neither necessary nor recommended for the patient’s dental health. 3) Dispensing of drugs not normally supplied in a dental office. 4) Services for injuries or conditions which are covered under Worker’s Compensation or Employer’s Liability laws. 5) General anesthesia/Conscious Sedation 6) Services that cannot be performed because of the general health, physical or psychological limitations of the patient. 7) Plan Participants cannot have other dental coverage.

Perio Membership

One-Time Fee:  $0.00

Plan Price:  $0.00

Total Charged Today:  $0.00

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