Horizon Dental Care Gold Dental Enrollment Application



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Your Profile

Name________________________________SSN______________________DOB_______________

Address__________________________________________________________________________

City____________________State__________Zip________________________________________

Home Phone_____________________________Cell______________________________________

Email Address__________________________________ Work phone________________________


Your Spouse Profile

Name________________________________SSN______________________DOB_______________

Address__________________________________________________________________________

City____________________State__________Zip________________________________________

Home Phone_____________________________Cell______________________________________

Email Address__________________________________ Work phone________________________


Your Children

Name_______________________ Age_______________________

Name_______________________ Age_______________________

Name_______________________ Age_______________________

Name_______________________ Age_______________________

Name______________________ Age_______________________


Enrollment Fees Credit Card Number_______________________

Adult= $197X ____=____ Exp date_____ CVV Code__________________

Children= $154X____=____ Total to be charged_____

Total=______ Authorized Signature___________ Date______

Terms and Conditions on Next Page

Terms and Conditions of Horizon Dental Gold Plan

Eligibility


  • This plan is only good at Horizon Dental Care.

  • This in-office discount plan is not a dental insurance.

  • To be a independent member you should be at least 18 years of age.

  • Your eligible dependents include spouse or domestic partner and children through the age of 25.

  • This plan cannot be applied with any other dental insurance or any other offers.

  • If the patient elects use a dental insurance; insurance plan fees, payments, and deductibles will apply.

  • All patients are subject to Horizon Dental Care policies.


Payments

  • Enrollment fees must be paid in full at the time of enrollment to receive discounts. A payment plan CANNOT be used for enrollment fees.

  • All payments for treatment must be paid in full at the time of service to receive discount. Any services that are not paid in full will be billed at our full fees.

  • All payments are non refundable.

  • No refunds will be given if the member does not use the plan benefits, relocates, or obtains dental insurance.

  • 12 months term effective from enrollment date or renewal date.

Exclusions

  • Invisalign and orthodontic treatment are discounted at 10% if the entire payment is made up front.

  • Plans and fees are subject to change yearly.

  • No discount is provided for services requiring a referral to a specialist outside of the practice.

  • Should treatment be needed following an injury of 3rd party insurance is involved the discount cannot be used.

  • Treatment initiated prior to enrollment is not eligible for discounts.

  • Prosthesis delivered or in progress treatment completed more than 60 days after the termination of coverage is not eligible for discounts.

  • Horizon Dental Care reserves the right to discontinue this plan for any member at any time.

  • Two no shows or cancellations without 48 business hours notice can lead to you being dropped from the program without any refund.

  • If you chose to extend your payments through a 3rd party financing such as Care Credit the dental discount will be reduced to 10% due to merchant fees.

  • Dental products are not included in discount.

I, ______________________________________ acknowledge the terms and conditions of Horizon Dental Care Gold Discount Plan. I understand that it is NOT a dental insurance but is an in-office discount plan.

Signature________________________________________________Date________________________



No Insurance? We have you covered!

Horizon Dental Care Dental Plan

We have designed this plan so everyone can have access to good dental care. We believe preventive care is essential for good oral and general health. The Horizon Dental plan is an affordable option for individuals and families with no dental insurance. We hope that you can utilize this plan to maintain and improve the dental health of your family for years to come. Please note that this is NOT DENTAL INSURANCE.

Annual enrollment fees:

Adults $197 Children $154



How to enroll?

  • Complete the application form and mail or fax to our office.

  • Pay enrollment fees to activate membership.

FEES

Two routine Dental Cleanings and Exams

Included

Unlimited Digital X-rays

Included

Oral Cancer Screenings

Included

Fluoride Treatment for Children

Included

One Emergency Visit

Included

Deep Gum Cleaning

20% off

Restorative Work (fillings)

20% off

Cosmetic Work

20% off

Implants

20% off

Root Canals

20 % off

Crowns and Bridges

20% off

Partials and Dentures

20% off

Extractions

20 % off

Please contact our office for more information and sign up for the plan!


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