Form

LC Quality Dental Membership Consent Form

Please read carefully and sign the section at the bottom of the form.

I consent to enroll in LC Quality Dental membership plan and agree to pay $368.00 yearly membership fee to get the checked treatment list below in the plan year:

Plan A:2 times regular cleaning, x-ray and exams. (Pano x-ray is not included)

-$75 for additional exam or x-ray for Plan A. (excl. Pano x-ray)
-10% off for all other treatments. (excl. bone graft, laser surgery)
-5% off orthodontics treatment paid at one time.
-$99 for additional cleaning.
-No show appointment membership clean will be forfeited.

I understand that these are not insurance plans therefore there are no claims forms. These are fee for service discount offers. I will receive dental treatment at the specified reduced fees set by this plan. Payment is due on the date all services are rendered.

Patient First Name

Patient Last Name

Patient Date Of Birth

Patient/Legal Guardian Signature

Date