www.delmarfamilydentistry.com - Savings Plan Contract Form

Savings Plan Contract Form
Renew by
Name*

First NameLast Name
Email
example@example.com
DMFDSP is a savings plan for families and individuals who don’t have insurance and still want to receive the best dental care. DMFDSP starts the day you sign your contract and runs for 1 year from the date signed. No waiting period or annual maximum.

The DMFDSP annual fee is $415 for the first member, and $380 for each additional family member. (Family members include spouse, and dependent children under age 23). The savings plan fee is due when the contract is signed and is non-refundable. With our savings plan, your total savings is over $1000. The family’s DMFDSP will expire on the same date.

*To receive the 15% savings on treatment, payment must be paid in full at the time of service.*

*A missed appointment fee of $100.00 per hour, will be charged for all missed appointments*

Please notify our office at least 48 hours in advance of your appointment if you must change a scheduled appointment. Phone calls only to reschedule or cancel.
BENEFITS:
- Two dental cleanings
- Two Exams
- One set of X-rays
- Yearly oral cancer screening
- Custom take home teeth whitening trays (includes 2 boxes of bleach)
- Enamel therapy treatment, as needed per visit
- 15% savings on all dental procedures, when paid in full @ time of service
- A 10% savings on Invisalign/Specialty Services
Signature*

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Name*

First NameLast Name
Date*

MonthDayYear
Date
Additional covered dependents:
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You are responsible to know when your plan expires.

** If you renew without lapse in coverage, you will get $25 off your plan renewal*
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Savings Plan Contract Form

BENEFITS:

Additional covered dependents: