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Upstate SmilesSavings PlanThe annual fee is $346_______________________________________________________________ The plan includes…?Two healthy mouth cleanings. $164 Value?Two examinations (new patient comprehensive and/or periodic hygiene)$137 Value ?Necessary x-rays for routine diagnosis at cleaning appointments. $95-$145 Value?Fluoride treatments at cleaning appointments as necessary. $90 ValueEstimated Initial Value $486-$536!!_______________________________________________________________ Then comes the BIG SAVINGS...$100 credit toward dental work.15% Savings on general dentistry procedures, including treatments for periodontal disease. (fillings, crowns, root canals, dentures, sealants, etc.)15% Savings on all cosmetic dentistry procedures including porcelain veneers.15% Savings on implant procedures.No Waiting Periods . No Insurance Red Tape _______________________________________________________________ Patient Name_____________________________Enrollment Date_____________________________Expiration Date_____________________________Terms & Conditions of Savings Plan:*The plan does not include treatment for periodontal disease (Scaling and Root Planing). This is a gum disease treatment, therefore, the $100 credit and/or 15% discount does apply. An $82 credit (cost of healthy mouth cleaning) will be applied to periodontal maintenance procedures. The patient is responsible for any remaining cost.*Bitewing and Panoramic x-rays are covered, as necessary, at cleaning appointments. If additional x-rays are necessary at other visits for diagnosis, they will be subject to the 15% savings (ie. Emergency visits).*The membership credit is never refundable, should it not be used for treatment.*The term of the membership is 12 months from the date of signing. Savings/benefits do not extend beyond the term for any reason other than renewal.*These savings are limited to services that can be performed by Upstate Smiles per the doctor’s discretion. Any procedure that is referred to another provider will not be included.*The savings cannot be combined with other discounts or special offers that may be offered through the internet, mailings, coupons, etc.*Patients with dental insurance are not eligible. *Discounts do not apply to orthodontic treatment (ie. Six Month Smiles)*Ongoing treatment like Six Month Smiles or extensive restorative work that has been initiated prior to enrollment is excluded.*There is a $1,000 maximum on discounts applied.*Any type of financing arrangement will reduce the in-house benefit discounts (ie. Care Credit). For 6 months no interest (for treatment exceeding $200), your in-house discount will be reduced to 10%. For 1 year no interest (for treatment exceeding $1500), your in-house discount will be reduced to 5%.By signing below, you are agreeing to the terms and conditions of this savings plan.___________________________________________Patient Signature Date ................
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