EmailMe Form - Stuart Pediatric Dentistry Membership Plan

Patient Name *
First Last
Parent / Guarantor Name *
First Last
Email *
Phone *
### - ### - ####
Membership Plan Disclosures
Our membership plan is not (i) insurance, (ii) a qualified health plan under the Affordable Care Act, (iii) pre-payment for future services, or (iv) payment for access to discounted services. Rather, our membership plan is a direct payment arrangement for services, products and care provided. The membership plan includes a 30-day money back guarantee. You can receive a full refund up to 30 days after purchase if no services or discounts have been used. Your payments must be current to receive the services and discounts included in the membership plan. Payment for treatment not included in the membership plan is due at the time of service. The membership plan benefits may not be combined with insurance or any other offers or discounts. Our membership plan does not cover procedures completed by specialists outside our practice. The membership plan runs for 12 months and includes an auto renewal feature. You can opt out of the auto renewal at anytime by calling us. You will receive an email reminder 45 days prior to the renewal date. For monthly plans, a $25 late fee will be applied if payments are more than 30 days late.
Acknowledgement *
I have read and understood the Membership plan disclosures
Membership Plan that you will like to belong to *
Monthly Plan -$35/month
Yearly Plan - $399/year
Payment Information
Name of Cardholder *
First Last
Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region
Credit Card Information *

Card Number

Protected in vault Data collected via fields that have our security seal are encrypted and stored with the highest global security standard — PCI compliance. Your data is absolutely safe in Vault.
Recurrent Charges Disclosure *
I authorize Stuart Pediatric Dentistry, P.A. to keep my signature and credit card on file and to charge my credit card as indicated in the disclosure. Please note that in the case of the Monthly plan a downpayment of $70 will be done when you sign up, and the first payment will be done the following month.
Acknowledgement *
I understand the recurrent charges disclosure
Today's Date *
MM / DD / YYYY
What team member Refer you
Signature *
Clear

EMF HTML Contact Form

Report Abuse

Payment Information