Dental Services Included:

• 2 basic cleanings per benefit per year OR
• 1 Perio-maintenance per benefit year (2nd perio-maintenance @ 20% discount)
• All diagnostic exams per benefit year
• Any necessary x-rays needed per benefit year
• Fluoride as recommended by Dr. Rubisch
• 25% discount on Major services and

Annual Cost:

• $250 for the first family member
• $240 for the second family member
• $230 etc.

Advantages of The Loyalty Program:

• No deductible
• No exclusions on services
• No insurance claims or estimates
• Savings: Annual costs of adult cleaning, periodic exam, 2 bitewing x-rays and fluoride are approximately $292.00- $326.00

Provisions:

The annual fee must be paid in full before the benefit year can begin. Benefit year is one year from the the purchase date. The plan cannot be combined with insurance, other discounts, or promotions. The program is non-transferable. Plan cannot be canceled during the benefit year, and no refunds will be made on annual fees. Payment for additional services must be paid at time or service or upon delivery. Plan is subject to change at the discretion of Dr. Rubisch, DDS.

I have read and agree to the provisions and inclusions of the Loyalty Program as written. I agree to the provisions and inclusions of the Loyalty Program as written. I agree to pay Dr. Rubisch or Draper Family Dentistry for work done at time of service to receive discounts due under the Loyalty Program.