Membership Form

YOUR CUSTOM DIAMOND MEMBERSHIP PLAN!

ONLY $399/year (16 AND OLDER) and you will receive...

• Up to 2 Exams and Routine Cleanings (PROPHY)
• Necessary X rays (Full Mouth 1x3yrs, Bitewings 1/year. additional as needed)
• Intraoral images as needed
• Invisalign scan (complimentary)
• 1 Emergency visit (Exam and X rays included)- during normal business hours ($150 copay per extra emergency appointment)
• Up to 2 Fluoride treatments when indicated
• 10% or more discount on All Other Treatment excluding Invisalign and Cosmetic Procedures
• Other Promotions apply throughout the year.
• ONE IN OFFICE TEETH WHITENING INCLUDED ($600 VALUE)

***if the patient is diagnosed with periodontal disease (Deep Cleaning) extra fees will apply for proper treatment

***Plan expires exactly 1 year after start date

ONLY $349/year for CHILDREN (UNDER 16)

• Up to 2 Exams and Routine Cleanings
• Necessary X rays (Full Mouth 1x3yrs, Bitewings 1x/year. additional as needed)
• Intraoral images as needed
• Invisalign scan (complimentary)
• 1 Emergency visit (Exam and X rays included)
• Up to 2 Fluoride treatments when indicated
• 10% or more discount on All Other Treatment except Invisalign
• Other Promotions apply throughout the year.

Plan expires exactly 1 year after start date

Whether, you use the Diamond Plan or not within the year, it will expire one year from the start date. The date provided on this form is the expiration date. The plan will need to be renewed after the expiration date to continue the savings!

**if Diagnosed with Periodontal Disease and a Deep Cleaning is required, then your intial payment will be used for your first 3 month cleaning after the deep cleaning is completed. Every cleaning appointment after that will be $150 until the plan expires and then a new payment of $399 will be required to continue the Diamond Membership Plan!