Form

Wellness Plan Enrollment Form

Jason D Lewis, DDS, FAGD
Royce M Barlow, DMD
55 Jaidev Road
St. Johns, FL 32259
T : 904-201-6000
F : 904-201-6004

Wellness Program Type

Adult New Patient (age 19 and over) - $599

Patient Full Name

Date of Birth

Email Address

Preferred Phone Number

Address

City

Zip Code

Exisiting Patient or Child (age 18 and under) - $499

Patient Full Name

Date of Birth

Email Address

Preferred Phone Number

Address

City

Zip Code

Total Cost - $599

Total Cost - $499

Credit Card Payment

Card Number

Expiration

CVC

Zip Code

Please initial next to each item acknowledging your acceptance of the terms.

I am enrolling in the Bartram Dental Center Wellness Plan.

Initial Here

I understand that this plan is not refundable and not transferable to another person.

Initial Here

I understand that the plan has a $2,500 maximum annual benefit limit per family member.

Initial Here

I understand that this plan can only be used at the Bartram Dental Center with Drs. Lewis and Barlow.

Initial Here

I have read and understand all the additional terms of the plan, and all my questions have been answered.

Initial Here

I understand that my Wellness Plan will be active for the next 12 months effective today.

Initial Here

Patient/Legal Guardian Signature

Today's Date