Form

Membership Plan

The Trillium Dental Membership Plan is an alternative method of payment that rewards you for your continued patronage to our office.

Name

Phone

Our annual membership plan includes:

2 exams with standard radiographs*
2 cleanings** including fluoride treatment
1 free whitening treatment***
20% discount of additional dental services and products (some exclusions apply)

*standard radiographs include bitewings once per year and panorex once every three years

**excludes scaling + root planing; additional cleanings available at discounted rate of $72

***limit 1 per patient per lifetime, AFTER completion of accepted dental treatment, custom take-home whitening tray only, in-office whitening available cost

The annual fee for a new membership is $450. Subsequent memberships will carry a fee of $400 annually. Please select the membership you would like to purchase below and be prepared to pay at your next appointment.

New Membership ($450 fee)

Membership Renewal ($400)

By signing this form, I consent to the financial obligation for the membership that I have selected above.

First Name

Last Name

Date Of Birth

Patient/Legal Guardian Signature

Date