This is NOT dental insurance 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.

• You must qualify for one of the Preventive Dental Club plans. Your individual plan will be determined by your dental hygienist and may require an initial evaluation appointment. Your dental health will be re-evaluated each year to determine if you still qualify for your enrolled plan.
• Patients with active periodontal disease may be required to complete comprehensive periodontal therapy before qualifying for one of the club plans.
• If you are a current patient enrolling in the Preventative Dental Club, your account MUST have a ZERO balance.
The plan is not retroactive 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-transferable.
• Plan price is based off the number of cleanings included in the plan. Therefore, the price for your plan will be determined at your initial examination.
• In exchange for the care provided under this plan, the covered member agrees to pay all balances in full at the time of treatment. If treatment is not paid in FULL at the time of service, the treatment discount is void.
• 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.
• Services are based upon a plan year. The full membership fee is due on the date of enrollment and eligibility will begin at that time remaining active for one year.
• If your dental practice allows monthly payment options, an enrollment fee may be applied. If you opt into monthly payments, the payment must be set up for automatic charge to a credit or debit card and email. A one-time credit card convenience fee will be charged with the first payment at every renewal date.
• This membership is an exclusive relationship between my dental office and myself. Smile Advantage LLC is in no way financially responsible for any member's treatment cost, refunds, charge backs 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.
• Membership prices subject to change at renewal.
• Plans cannot be combined with any other offer.

By enrolling in the Preventive Dental Club plan at this dental office, I acknowledge that I have reviewed, understand, and agree to the terms and conditions of the Smile Membership as presented by dental office upon enrollment. I authorize this dental office to process my payment as listed in this