The King George Dental Discount Plan

It is not dental insurance, it is better! It’s a membership plan that provides a reduction of fees on ALL dental procedures. No problems with copays, pre-determinations, coinsurance, frequency limitations, exclusions, deductibles, maximum allowance, pre-existing condition clauses, procedure downgrades, waiting periods, missing tooth clauses, and all other insurance company scam tactics.

Included in your membership: all exams and x-rays are free (this even includes emergencies). You are entitled to two free regular cleaning (deep cleanings are extra). It covers 12 consecutive months and can start at any date. Membership is not prorated. All elective (even cosmetic) procedures are covered. All procedures get a 20% reduction of our fees. Membership dues are paid at your initial visit. Payment is due at the time services are rendered.

Name: ___________________________________________________________

Address:_________________________________________________________

Birthday: ____________________ E-mail: ______________________________

Annual Membership: starts on this date ____________

_____ individual $275/year

_____ additional spouse $250 year

_____ each additional family member $225/year.

By signing below, I understand and agree to the terms of this plan and acknowledge that this Dental Discount Plan is not insurance and cannot be used in any other dental office.

Signature: _______________________________________ Date: _____________