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Smile Advantage Dental Plan (online registration)
Brought to you by VIP Dental Lounge
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PLAN TERMS AND CONDITIONS: This is NOT dental insurance, rather a savings plan. This savings plan cannot be used in conjunction with dental insurance or other discounts. This plan is only valid at this dental office. Care from other providers or specialists is not included. 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.• The plan is 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-transferable.• It is the patient’s responsibility to inform this dental office of changes in billing information due to expired credit/debit cards, etc. Expired cards are not a valid reason for non-payment. If we are unable to process a member’s monthly payment, the Smile Advantage Plan is VOID until payment is made. Any unused benefits during this time are relinquished. Any scheduled future appointments will be canceled and cannot be rescheduled until account is in good standing.• This is a 1 year contract; however, in case of an early termination, the 15% discounts applied will be void and charged to the credit card on file.• To enroll using the monthly payment option, a 4 month charge will be applied and the regular monthly fee to be charged from the 5th month onwards.• A valid credit/debit card must be kept on file and the card will get automatically charged monthly or yearly depending on the payment option chosen.• Your membership will automatically renew at the end of each plan year unless you choose to cancel it. *
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Your Smile Advantage Plan Includes: Up to 2 Exams & Routine CleaningsPerio Plan; Up to 4 Perio Maintenance Cleanings & 2 Exams; Necessary X-rays (Full Mouth 1x/3yrs, Bitewings 1x/1yr, additional as needed); Intraoral images as needed; 2 Emergency Care Visits: Exams & Necessary X-rays; VELscope® ; Oral Cancer Screening; Up to 2 Fluoride Treatments when Indicated; 15% Discount on All Other Dental Treatment (excludes Invisalign/Clear Aligners); $500 off Invisalign/Clear Aligners
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Middle Name *
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Last Name *
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City *
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State *
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Zip Code *
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Preferred Phone Number *
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Please select your plan option *
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Total # of children enrolling for the Child Plan:
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Total # of adults enrolling for the Adult Plan:
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Total # of patients enrolling for the Perio Plan:
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Setup fees will be due at the time of enrollment with prorated payment for first month. Additional monthly payments will be processed on the 1st of each month or the following business day: Children (ages 12 and under) -$199/yr or $19/month; Adults (ages 13 and over) - $299/yr or $29/month; Perio Plan - $399/yr or $39/month. *
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Select your preferred method of payment: *
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Select your preferred credit card for payment: *
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Please enter cardholder name for above method of payment exactly as it appears on the card: *
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Please enter your 16-digit credit card number: *
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Enter the expiration date for the above credit card in MM/YY format. (ex. 01/19 for January 2019) *
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Please enter the 3- to 4-digit security number from the back of your credit card:
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By entering my name below, I acknowledge that I have reviewed, understand, and agree to the terms and conditions of the Smile Advantage Plan. I authorize this dental office to process my payment as listed in this Agreement. *
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A copy of your responses will be emailed to the address you provided.
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