Arsmiles Dental Savings Plan Agreement

1. Arsmiles Dental Savings Plan is NOT a dental insurance. It is a discount savings program. The intent of this Plan is to benefit patients without dental insurance.
   
   
2. This enrollment form and Agreement and Acknowledgement, signed by the Arsmiles Dental Savings Plan member, or Guarantor (herein referred to as “patient” or “member”), and accepted by Arsmiles family & cosmetic dentistry, shall be considered to be the contract, membership materials and all disclosure information relating to the Arsmiles Dental Savings Plan.
   
   
3. Membership premium is due at the time of the first exam. No discount will be given until the membership premium is paid in full.
   
   
4. Dependents are defined as children or legal dependents who are unmarried, 18 years of age, and younger.
   
   
5. The patient is responsible for the entire payment of his/her dental bill after the discount is applied at the time services are rendered.
   
   
6. Cancelation/rescheduling needs to be done within 72 hours prior to the appointment. There is a $50 fee for the first time; second time occurrence is $50 and losing membership privileges.
   
   
7. Arsmiles family & cosmetic dentistry reserves the right to change discounted fees once a year. Normally, such changes are made during the first quarter of each calendar year. Yearly membership premium fees may be changed at the beginning of a new contract term with notice given to the member at time of renewal.
   
   
8. The patient may, with or without cause, within 15 days after the day on which this contract is signed by the patient (see “Acknowledgement” below), cancel the contract without payment, damages, penalty, or liability of any kind by giving WRITTEN notice of cancellation to Arsmiles family & cosmetic dentistry, provided the patient has not used the services of Arsmiles Dental Savings Plan. The annual premium fees collected will be refunded to the patient, and the contract will be considered void.
   
   
9. The Plan is valid for one year from the date this is signed, and the premium is paid.

1. The dentist will provide services to patients, including services for pre-existing conditions, at the agreed-upon discounted price. A patient may be referred to a specialist who is not a participant in the program; treatment requiring a specialist is not covered under this program.
   
   
2. The two cleanings in this Plan are standard cleanings WITHOUT the presence of periodontal disease. If you are diagnosed with active periodontal disease, you may require scaling and root planning, which will be discounted under the dental plan. Following the scaling and root planning treatment procedure, you will be placed on a periodontal disease maintenance treatment schedule.
   
   
3. Cosmetic procedures such as teeth whitening are only included in the Premier discount Plan.
   
   
4. The dentist and staff will provide quality dental care and will at all times comply with Ohio State law relating to the practice of dentistry.

I acknowledge receiving, reading, and understanding the terms of the Arsmiles Dental Savings Plan. I agree to abide by all terms outlined above. I understand that all discounted fees are due at the time of service for the treatment rendered. I understand that this is NOT dental insurance but a dental discount savings Plan.