Healthy Smiles Program Exclusively by Park Avenue DentalA friendly alternative to expensive dental insurance plans or lack of dental insurance. "*" indicates required fields CommentsThis field is for validation purposes and should be left unchanged.This Program Covers: Two Periodic Exams (Comprehensive Oral Exam and Oral Cancer Screening) per year. One Emergency or Limited Exam per year. Two Professional Cleanings per year. Fluoride treatment for children at every cleaning and adults as needed. Yearly necessary dental X-rays (excluding Panographic or CBCT Imaging). 10% discount on all procedures (excluding dental implant procedures). No Pre-existing conditions. No Deductibles, no waiting periods, no maximums on benefit coverage Free Phone or Office Consultations with the Doctor. Tax Deductible Fees for the Healthy Smiles Program: Individual Adult Plan $500/year Pediatric Plans (1 - 15 years old) - $250/year Senior Citizen Plan (>65 years old) - $400/year* *Unlimited Exams for Seniors or Disabled* This plan must be paid in full at the time of enrollment. It is non-transferable, non-refundable, and cannot be pro-rated. Membership will automatically renew annually unless we receive written cancellation within 30 days of the expiration date. This plan is a preventative oral health plan membership and is not a dental insurance plan. I understand the above guidelines and limitations and agree to purchase the Healthy Smiles Program, which will be in effect for one yearfrom*to*Patient, Print Name*Patient Signature*Date MM slash DD slash YYYY