Commonwealth Care Membership

Commonwealth Care Membership - Child

Fill out the short form below to get your comprehensive dental membership! Child must be under 13 and Parent/Guardian must be at least 18 years old to enroll child(ren).
Enrollment Date*
Date

MonthDayYear
Date
Parent/Guardian Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Email*
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is Your Child(ren) An Existing Patient?*

YesNo
Preferred Commonwealth Dentistry Location*
Children's Information

Enroll your children into a Commonwealth Care Membership. Select how many children (13 & under) you choose to enroll and provide us their names and birth dates.
How Many Children Are You Enrolling?*
Membership Cost Calculator - Monthly
Membership Cost Calculator - Annual
Enter your Child(ren's) Full Name and Date Of Birth*
Membership & Payment Details

Select your membership subscription level and enter your payment details. You will be able to confirm your information on the next page

Child Monthly Plan

USD for each month

Child Annual Plan 1 Month Free With Annual Subscription

USD for each year

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Location
*

I understand that a minimum enrollment period of ninety (90) days is required and if I choose to cancel my membership during this time period, I agree to pay in full for any services rendered at our current fee schedule.
*

I understand that if Periodontal Disease is present, additional treatment may be necessary, and such treatment would require additional services beyond routine cleanings and maintenance to treat this disease.
*

I agree with the Dental Membership Plan Terms and Conditions below
TERMS & CONDITIONS: The Commonwealth Care Membership is NOT A DENTAL INSURANCE PLAN and not intended to be a substitute for a dental insurance plan. The Membership can be canceled at any time but a refund will only be issued if canceled in the first 90 days. If services are rendered in the first 90 days and the Membership is canceled, you agree to pay in full for any services at our current usual, customary, and reasonable (UCR) fees. If Scaling and Root Planning (a.k.a. ‘deep cleanings’) are advised due to periodontal disease, the Perio Maintenance Plan will be recommended providing members up to 4 Perio Maintenance Cleanings and the member discount of 15% will apply to the Scaling and Root Planning procedure(s). You must be current on all membership fees in order to receive any services included in the plan or discounts on additional treatment. The credit card on file will be automatically charged monthly or annually, depending on the Membership selected, until canceled. Payments for additional dental services are the member’s responsibility. Payment is due on the date of service to qualify for the discounts detailed in the plan. Payments for additional dental services are the member’s responsibility. Payment is due on the date of service to qualify for the discounts detailed above. The Membership is non-transferable and no refunds will be issued if the participant decides not to or is unable to, utilize the Membership, or for any reason. The Commonwealth Care Membership is only valid for services rendered at our affiliated locations and cannot be used anywhere else. We use a third-party payment processor to collect and process all payments. It is your responsibility to provide accurate and up-to-date payment methods and information. If you do not provide a valid payment method, or if your payment method becomes inactive for any reason, we may immediately discontinue your enrollment in the Dental Membership Plan. We will attempt to reach out to you via text or email to gather up-to-date and accurate information prior to cancellation. We reserve the right to change the fees associated with the Membership plan should increases in product or labor rise due to circumstances beyond our control. We will notify you at least 30 days prior to any such change or increase. Should a default occur and a member's account is assigned to collections, the member agrees to pay and all fees including collection agency and other attorney fees (not to exceed 25%), court costs and any other fees advanced by this office to collect on any default.
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Commonwealth Care Membership - Child

Children's Information

Membership & Payment Details