Form

Account Holder First Name

Account Holder Last Name

Date Of Birth

Address

City

Zip Code

SSN

Home Phone

Cell Phone

Gender

Marital Status

Are there any additional patients on this membership plan?

First Name

Account Holder Last Name

Date Of Birth

Same Address?

Address

City

Zip Code

Home Phone

Cell Phone

Gender

Relationship to Account Holder

Are there any additional patients on this membership plan?

First Name

Account Holder Last Name

Date Of Birth

Same Address?

Address

City

Zip Code

Home Phone

Cell Phone

Terms and Conditions

The Sparks Dentistry Dental Membership Plan is NOT a dental insurance; it is a loyalty membership discount plan offered by Sparks Dentistry. The Plan and any discounts included do not cover procedures performed outside of our practice. Please initial all items below:

I have the right to cancel your membership at any time. I must contact Sparks Dentistry directly to cancel. Please keep in mind that this plan is NON-REFUNDABLE.

Membership benefits will not begin until payment and signed paperwork is received in full by the office. Sparks Dentistry does not offer payment plans for In-Office Memberships.

During the term of my Membership, I will not be charge for Included Services*. I will be responsible for all discounted fees of Non-Includes Services**.

Sparks Dentistry will notify me prior to the end of your Membership term. I may then choose to renew my Membership for another year.

Membership benefits will not continue following the termination of my Membership period if I have not chosen to renew your Membership, and if payment and paperwork has not been received in full by our office.

The In-Office Membership Plan may not be combined with any other discounts, discount plans, or dental insurance (including any private insurance plan or policy). The discounts will not be applied to any purchased products (i.e. bleaching materials, toothpaste).

Any late cancellation or missed-appointment fees that the Dentist may charge will still apply and will be my responsibility. (If you need to change or cancel an appointment, please call the office within 24 hours of the scheduled appointment to avoid these fees.)

Discounts from the Dental Membership plan is not retroactive for previous procedures prior to the date that payment and paperwork are received in full. The included services must be completed within the contract year. Services cannot be rolled over.

*Included Services:

2 Routine Dental Cleanings
2 Fluoride treatments
2 Exams
1 Routine Panoramic X-ray
1 Set of Bitewing X-rays
1 Emergency visit with necessary X-rays

**Non-Included Services

20% discount on non-cosmetic dental procedures
10% discount on implants and cosmetic dental procedures
NO discount on Tempsure procedures

By joining the Sparks Dentistry's Membership Plan, the Account Holder acknowledges and agree to the TERMS AND CONDITIONS above: