This is NOT dental insurance but rather a membership plan. This membership serves as an exclusive agreement between our patients and our practice. This membership plan cannot be used in conjunction with dental insurance or any other discounts. This plan is only valid at this dental office. Plan fees are subject to change.

If you are a current patient enrolling in the Smile Advantage Plan, your account MUST have a ZERO balance.

If periodontal infection is present, the member may be required to upgrade to the Perio plan.

Scaling and root planing are not included in the Perio plan but those services are eligible for the 15% discount.

Youth plan is intended for children ages 12 and younger. Eligibility for this plan is based on child’s age at the time of enrollment.

15% off of other dental care treatments excludes fillings, sealants, whitening, Botox, Juvéderm, clear aligners, retainers, and products.

Target X-rays are not included in emergency visit.

For Artistry Plan, the 20% off discount is valid for included cosmetic treatments until discretionary funds are used up.

The plans are not retro-active and will become effective on the date of enrollment.

It is the member’s responsibility to utilize the services included in this agreement within their plan year limit. Any unused benefits will not be carried over or refunded. The plan is non-transferrable.

In exchange for the care provided under this plan, the covered member agrees to pay all balances in full at the time of treatment. Failure to follow our patient financial responsibility will void discounts included in this plan.

Memberships, regardless of payment schedule, will be auto-renewed at the end of each plan year.

The member has the right to opt out of the plan for a full refund within 30 days of enrollment as long as treatment has not started. If ANY treatment has been performed or if 30 days from enrollment have lapsed, NO refund will be given. The member will be responsible for paying the remaining balance regardless of services rendered.

If you need to spread the cost of the membership plan, a monthly payment option is available. Monthly payments must be made using a credit or debit card. All plans, regardless of payment schedule, require an annual commitment. If you choose to cancel your plan prior to the end of the plan year, the remainder of the monthly payments will be charged to your credit or debit card in a lump sum. No refunds will be available. For yearly payments, the full membership fee is due on the date of enrollment. Eligibility will begin at that time, remaining active for one year.

This membership is an exclusive relationship between Belpre Dental Studio and myself. Smile Advantage LLC is in no way financially responsible for any member’s treatment cost, refunds, chargebacks, or additional fees.

If the membership plan is not utilized within the year, it cannot be carried over to the next year. This means that any unused benefits, such as free cleanings or discounts, will expire at the end of the membership term. Please note that it is important to schedule your appointments in a timely manner to ensure that you receive the full benefits of your membership plan. If you do not schedule your appointments and your membership expires, you will need to renew your membership to receive the benefits again.

By enrolling in the Smile Membership plan at this dental office, I acknowledge that I have reviewed, understood, and

agree to the terms and conditions of the Smile Membership as presented by Belpre Dental Studio upon enrollment.

I authorize Belpre Dental Studio to process my payment as listed in this Agreement.