224 Shallowford Road NW, Gainesville, GA 30504

No Insurance?   No Problem!!!

Legacy Family Dentistry  is pleased to now offer a Dental Care Wellness Plan to our patients who do not have dental benefits.  This plan allows patients the opportunity to get the dental care they need and want without breaking the bank!  The plan is available to both new and existing patients of the practice.  Not having traditional dental insurance should not stand in the way of needed dental treatment.  Knowing that dental insurance premiums are expensive and that those benefits are extremely limited, we have created a comprehensive and customized membership program that will cover 100% of your preventive care in our practice, including cleanings, xrays, exams…and so much more!

The best part is that this plan involves no deductibles, no claims processing, no maximums and no exclusions!

What you will receive:  During the covered period of 12 months (starting at any day of the year you choose), you will receive:

  1. Two Comprehensive Dental Exams by Dr. Jorgensen with your check ups.
  2. Xrays: One Full Mouth Set of Xrays (18 films), 6 Vertical Bitewing Xrays or 2 Bitewing Xrays (depending on your age and the last time you had Xrays)
  3. Two Routine Dental Cleanings for a Healthy Mouth (deep cleanings/Scale and Root Plane treatment for gum disease is different and will be charged at 85% of our normal fee, which reflects the 15% automatic discount of your wellness plan). This type of treatment usually means that you will need to be seen more frequently for the maintenance of your gum health. Patients on a 4 month recall schedule will have 3 more extensive cleanings per year and we will discount 15% of the first two maintenance treatments and the third one is covered at 100%.   For patients who are on a three month recall schedule, we will discount the first two maintenance treatments by 15% and the third and fourth maintenance treatments will be covered at 100%
  4. Fluoride Varnish treatment at all cleanings
  5. Oral Cancer Screening at all cleanings
  6. Emergency Exam/Xrays: One extra emergency exam with needed xrays per year
  7. An automatic 15% discount on all other dental treatment; no exclusions or maximums. Bleaching and Cosmetic procedures which are often excluded by typical insurance plans are all covered under this plan and at a 15% discount!

Membership  Details

Plan Term is for 12 months (see below for details)

Single —$30.00 per person, per month.  For one person, represents more than a $650 value, PLUS 15% discount on any other dental services.

Double–$50.00 per couple, per month.  For any two family members living at the same address; this represents more than a $1350 preventive value, PLUS 15% discount on any other dental services.

Family—-$90.00 per family, per month. For up to four family members living at the same address; this represents more than a $2600 preventive value, PLUS 15% discount on any other dental services.

Large Family–$150.00 per family, per month. For up to seven family members living at the same address; this represents more than a $3900 preventive value, PLUS 15% discount on any other dental services.

***There is no age restriction as long as all covered family members live at the same address; college addresses are considered temporary housing, so college students are also covered by the plan, no matter their age***

Stipulations

A one-time set up fee of $5.00 per person will be charged upon initiation, so we know exactly who is covered by the plan (Please fill out the attached Application Form).

All payments for routine dental services (not including all covered check ups) will be discounted 15% and must be paid at the time of service.

Membership cannot be combined with any other discount or insurance plan.  Membership is only valid at Legacy Family Dentistry.

It is the responsibility of members to maximize their benefits by scheduling the appropriate appointments within the 12 month membership period.  You will receive emails, post cards and text message reminders about when you are due for your appointments.

Unused appointments and benefits will not carry over to the following year.

Legacy Family Dentistry   Wellness Membership Plan

TERMS AND CONDITIONS: The (“Agreement”) will govern the Wellness Plan Membership as described herein by  (“Dentist”) to you (“Patient”), and by enrolling in the Wellness Plan, you hereby agree to be bound by this agreement.

AGREEMENT

The Parties agree as follows:

THE WELLNESS PLAN

Wellness Plans provide specific Dental Services as well as discounts on other services not included in the Wellness Plan.  Membership in this Wellness Plan is voluntary and made available exclusively by Legacy Family Dentistry to its patients.

Wellness Plan Fees

The Patient shall pay monthly fees to Legacy Family Dentistry for a Wellness Plan based on how many family members the Wellness Plan covers.  The Fees shall be payable in equal monthly installments and will commence on the date of enrollment.  Fees shall be billed each subsequent month on the same day as the enrollment day (the date of billing may be adjusted for days falling on non-business days).  The Patient will receive a monthly email detailing such payment.

Automatic Payments

The Patient hereby authorizes regularly scheduled charges to his Visa, MasterCard, American Express, DiscoverCard or checking account.  The Patient will be charged each billing period for the total amount due for that period.  A receipt will be sent to the Patient and the charge will appear on the Patient’s credit card or bank statement.  The Patient agrees that no prior notification will be provided if the total payment is no more than the fees described herein.  The Patient understands that this Authorization will remain in effect until cancelled in writing and agrees to notify Dr. Kristin Jorgensen/Legacy Family Dentistry in writing of any changes in the Patient’s account information or the desire to terminate this Authorization at least five (5) days prior to the next billing date.  The Patient certifies that he or she is the authorized user of the designated credit card and will not dispute the scheduled payments with such credit card company, provided the transactions correspond to the terms described herein.

 

Terms and Termination

Subject to the termination rights herein, this Agreement is for a term of 12 months, commencing on the date written on the Application.  This agreement shall automatically renew for successive 12 month periods thereafter.  Either party may terminate this Agreement at any time upon five (5) days prior written notice to the other party.  Dr. Jorgensen may terminate this Agreement immediately if the Patient breaches any of his or her obligations under this Agreement.  If the Patient terminates this agreement during the first six (6) months of the term hereunder, the Patient shall immediately be charged a termination fee of $150.00 for each family member covered under the Agreement.  Thereafter, the Patient will not be subject to any such termination fee.  Regardless of any termination by the Patient, the Fees paid prior to the date of the termination shall be non-refundable.

Obligations of the Patient

The Patient hereby agrees to perform the following as a member of the Wellness Plan being offered by Legacy Family Dentistry:

  1. Develop an understanding of the Wellness Plan being offered by Legacy Family Dentistry.
  2. Enroll in the Wellness Plan by setting up an account with the office, including but not limited to, the name and birthday of all family members enrolled in the plan, their address, telephone number, cell number, email and fax numbers (where applicable).
  3. Pay the Fees to Legacy Family Dentistry as they become due.

***In the event the Patient fails to pay the Fees under this Agreement, the Patient shall be in default and Legacy Family Dentistry will have the right to exercise any and all legal or equitable remedies available to the Practice, including the right to immediately terminate the Patient and the Patient’s family member(s) from the Wellness Plan***