Dental Membership Plan in Livermore (No Insurance Needed)

Please choose the package(s) that suit your needs:

$499/year Adult Membership $599/year Adult on Periodontal Maintenance $399/year Child Membership (13yrs & under)

Personal Information

I understand and agree that any information submitted will be forwarded to our office by email and not via a secure messaging system. This form should not be used to transmit private health information, and we disclaim all warranties with respect to the privacy and confidentiality of any information submitted through this form.

First Name

Last Name

Date of Birth

Mobile phone number

Home Address

City

State

ZIP Code

Membership Agreement

Please read and check each box to agree:

Not insurance: This is an in-office membership plan, not dental insurance. Membership fee: Paid in full at enrollment. It’s prepaid, non-refundable (even if I don’t use my plan) and non-transferable, and accounts can’t be frozen. Treatment payments: My share of treatment costs is due in full at each visit. If I pay with CareCredit or Sunbit, my treatment discount drops from 20% to 10% because of merchant fees. Discount limits: The discount doesn’t apply to implants, Invisalign or cosmetic cases, and can’t be combined with other discounts or promotions. Appointments: Missed or rescheduled appointments without 48 hours’ notice have a $75 fee. Plan term: Benefits must be used within 12 months of enrollment. The plan may change each year, and membership may end if fees aren’t paid.

Signature

Date

Human check

	Adult Membership $499	Child Membership $399 *children qualify as age 13 & under.	Adults on Periodontal Maintenance $599
2 Routine Exams
1 Emergency Exam
2 Regular Cleanings
1 Set of X-Rays
2 Fluoride Treatments
20% Off Treatment
3 Periodontal Maintenance Cleanings + Adult Membership Benefits (not including 2 regular cleanings)

Dental Membership Plan

Annual Membership Fee

Membership Experience

No annual maximum

No limitations for pre-existing treatment

No deductibles

No waiting periods

No denied claims

No pre-authorizations

Membership Form

2832 Las Positas Rd, Livermore, CA 94551

Livermore: (925) 449-7900

2832 Las Positas Rd, Livermore, CA 94551

Fremont (Mowry Dental): (510) 794-7900

39355 California St, Suite 100, Fremont, CA 94538

(925) 449-7900

2832 Las Positas Rd. Livermore, CA