Savings Plan Signup

"*" indicates required fields

1Sign Up

2Payment

Member's Name*

First Middle Initial Last

Date of Birth*

Membership*

Member's Name*

First Middle Initial Last

Date of Birth*

Membership*

Member's Name*

First Middle Initial Last

Date of Birth*

Membership*

Member's Name*

First Middle Initial Last

Date of Birth*

Membership*

Member's Name*

First Middle Initial Last

Date of Birth*

Membership*

Member's Name*

First Middle Initial Last

Date of Birth*

Membership*

Member's Name*

First Middle Initial Last

Date of Birth*

Membership*

Member's Name*

First Middle Initial Last

Date of Birth*

Membership*

Member's Name*

First Middle Initial Last

Date of Birth*

Membership*

Member's Name*

First Middle Initial Last

Date of Birth*

Membership*

Additional Family Members: +

Guardian's Name

Only applicable if a member is under 18.

First Last

Multi Member Discount

Total

Terms and Conditions:

The Davies Dental Savings Plan is governed by the following terms and conditions. All individuals purchasing memberships with Davies Dental should understand these terms and conditions before purchasing a membership and receiving its benefits. Davies Dental reserves the right to make changes to these terms and conditions at any time.

This in-office discounted plan is NOT dental insurance and it is only good at Davies Dental.
No discount will be offered for procedures requiring the services of a dental specialist (endodontist, orthodontist, periodontist, pedodontist, etc.) who is not employed within the Davies Dental organization.
Plans and fees are subject to change yearly.
Memberships include coverage for the individual only. Membership privileges do not extend to family members. Separate plans will need to be purchased for family members.
Plan cannot be utilized if you have any dental insurance plan or any dental insurance coverage.
Plan cannot be used in addition to or in conjunction with any discount dental plan or other office discount.
It is the responsibility of the member to inform Davies Dental that they are a member when making an appointment and at check-out.
Members are entitled to receive discounts on specified services. Members must pay the provider directly at time of service unless otherwise agreed upon.
If you choose to extend your payment for treatment by paying through a third party lender the treatment discount for service is reduced by 5% due to merchant fees.
No discount will be given for nitrous oxide or oral conscious sedation.
No discount will be given for any retail product sold in the office including all oral health products and take-home whitening products.
Any services that are not paid in full at the time of service will be billed at our regular standard fees.
Enrollment fees must be paid in full to receive discounts.
Memberships are non-refundable and the term is effective from the sign-up date to the 12-month anniversary date at which point benefits expire.
Treatment initiated prior to enrollment is not eligible for discount.
In-progress treatment completed/delivered more than 30 days after termination of coverage is not eligible for discount.
Treatment fees are guaranteed for 90 days from the date quoted by the office.
Two no-shows or cancellations without 24-hour notice will lead to you being dropped from this plan without a refund.
No refunds will be given if a member and/or spouse or children do not use the plan, relocate, or obtain dental insurance.
Davies Dental reserves the right to discontinue this plan for any member at any time.

Name*

First Last

Email*

Signature*