Enrollment Form

Application Form

Patients must have a zero balance for consideration. This Membership Plan is not dental insurance and is not transferable to other dental offices. Our Membership Plan is only available to patients who do not have existing dental insurance, anticipate discontinuing their current dental insurance, or using it after insurance maximum has been met.  It is solely the patient’s responsibility to schedule and keep their appointments.  No refunds will be provided for dues paid, including failure to schedule and maintain appointments.  Please notify our office at least 48 hours in advance if you must change a scheduled appointment. Fees for dental services may change at any time. By checking the box below, I  understand and agree to the terms outlined above.

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