As Low as Dental Coverage Membership Plan...Dentistry Affordable for You! Affordable Dental Coverage...
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As Low as $21 /mo. We’re Making Excellence in Dentistry Affordable for You! Affordable Dental Coverage Membership Plan For You & Your Entire Family Low-Cost Dental Coverage As Low as $21 /mo. Join Texas Dental Resources’ In-House Premier Dental Coverage Membership Plan You save on everything from cleanings & fillings to cosmetic procedures & crowns! • All Health Conditions Accepted! • You Cannot Be Denied Coverage! • No Deductibles! • No Health Questions! • You Cannot Be Singled Out for Rate Increases or Cancellations! Please List All Unmarried Children Up to Age 20 1. Child’s First Name _________________________ Middle Initial ______________ Son / Daughter Date of Birth ______________________________ 2. Child’s First Name _________________________ Middle Initial ______________ Son / Daughter Date of Birth ______________________________ 3. Child’s First Name _________________________ Middle Initial ______________ Son / Daughter Date of Birth ______________________________ 4. Child’s First Name _________________________ Middle Initial ______________ Son / Daughter Date of Birth ______________________________ 5. Child’s First Name _________________________ Middle Initial ______________ Son / Daughter Date of Birth ______________________________ Please Fill out & Send This Form in Today to Begin Coverage! Enroll Today! TDR T EXAS DENTAL R ESOURCES 1-877-617-2320 1-817-605-6297(fax) P.O. Box 54876, Hurst, TX 76054 TexasDental.org TDR T EXAS DENTAL R ESOURCES ID# 4560 © December 2016 chrisad, inc., marin co., ca all rights reserved. • Comprehensive Exam (once every six months) • Fluoride Treatment for Children (under the age of 18, once every six months) Our Affordable Coverage Includes the Following Services at No Charge: • X-Rays • Cleaning (Prophylaxis) (once every six months)
Transcript of As Low as Dental Coverage Membership Plan...Dentistry Affordable for You! Affordable Dental Coverage...
As Low as$21 /mo.
We’re Making Excellence in Dentistry Affordable for You!
AffordableDental CoverageMembership PlanFor You & Your Entire Family
Low-Cost Dental CoverageAs Low as $21/mo.
Join Texas Dental Resources’In-House Premier Dental
Coverage Membership PlanYou save on everything from cleanings & fillings to cosmetic procedures & crowns!
• All Health Conditions Accepted!
• You Cannot Be Denied Coverage!
• No Deductibles!
• No Health Questions!
• You Cannot Be Singled Out for Rate Increases or Cancellations!
Please List All UnmarriedChildren Up to Age 20
1. Child’s First Name _________________________ Middle Initial ______________ Son / Daughter Date of Birth ______________________________
2. Child’s First Name _________________________ Middle Initial ______________ Son / Daughter Date of Birth ______________________________
3. Child’s First Name _________________________ Middle Initial ______________ Son / Daughter Date of Birth ______________________________
4. Child’s First Name _________________________ Middle Initial ______________ Son / Daughter Date of Birth ______________________________
5. Child’s First Name _________________________ Middle Initial ______________ Son / Daughter Date of Birth ______________________________
Please Fill out & Send This Form in Today to Begin Coverage!
Enroll Today!
TDRTEXAS DENTAL
RESOURCES
1-877-617-23201-817-605-6297(fax)
P.O. Box 54876, Hurst, TX 76054TexasDental.org
TDRTEXAS DENTAL
RESOURCES
ID# 4560 © December 2016 chrisad, inc., marin co., ca all rights reserved.
• Comprehensive Exam (once every six months)
• Fluoride Treatment for Children (under the age of 18, once every six months)
Our Affordable Coverage Includes the Following Services at No Charge:
• X-Rays
• Cleaning (Prophylaxis) (once every six months)
Please Fill out & Send This Form in Today to Begin Coverage!
Patients agree that Texas Dental Resources fees stated must be paid at the time services are rendered. Any service not paid for at the time of service will be billed at usual & customary fees. Coverage fees are valid only when paid at the time of enrollment. All family members must reside in the same household. This is not an insurance product.
First Name ________________________________________
Last Name ________________________________________
Middle Initial ________________________ Female / Male
Home Address _____________________________________
__________________________________________________
City _____________________ State ______ Zip ________
Phone ____________________________________________
Email _____________________________________________
Date of Birth _____/_____/_____ S.S.#_____-_____-_____
Spouse First Name __________________________________
Last Name ________________________________________
Middle Initial ________________________ Female / Male
Date of Birth _____/_____/_____ S.S.# _____-_____-_____
Enrollment Period _______________ to _______________
Signature (member & spouse)
__________________________________ Date ___________
__________________________________ Date ___________
American Express / Discover / MasterCard / Visa
Card Number ______________________________________
Expiration Date ____________________________________
I understand that with my signature I am allowing my account to be debited once a month.
Email: [email protected]
Low-Cost Dental Coverage• Individual ~ $21/mo.*
• Individual & Spouse ~ $31/mo.*
• Family Plan ~ $55/mo.* (two adults & two kids)
• Additional Child in Family ~ $10/mo.**Monthly payment plan is available to patients providing direct deposit or credit card access.
Now you can join our low-cost dental coverage for a nominal membership fee. Our coverage entitles you to preventive dental care at no cost! Corrective services are available for small co-payments that are far less than the usual, customary fees. Our professional staff is qualified to care for all of your dental needs!
To enroll, simply fill out the enclosed enrollment form & return it with your check, money order or credit card information. Please make check or money orders payable to Texas Dental Resources.
Low-Cost Dental Coverage
Examination . . . . . . . . . . . . . . .No Charge . . . . . . . . . . . $65
X-Rays . . . . . . . . . . . . . . . . . . .No Charge . . . . . . . . . . $138
Bitewings (4 films) . . . . . . . . . . .No Charge . . . . . . . . . . . $83
Adult Cleaning . . . . . . . . . . . .No Charge . . . . . . . . . . $118(every six months) (prophylaxis, in absence of gum disease)
Children’s Cleaning . . . . . . . . .No Charge . . . . . . . . . . . $82(every six months)
Fluoride Treatment . . . . . . . . .No Charge . . . . . . . . . . . $31(for dependent children)
Preventive Dentistry
Service Co-Payment“Basic Care”
Regular Feesas High as
Filling (1 Surface) . . . . . . . . . . . . $180 . . . . . . . . . . . . $225
Filling (2 Surfaces) . . . . . . . . . . . . $235 . . . . . . . . . . . . $294
Filling (3 Surfaces) . . . . . . . . . . . . $286 . . . . . . . . . . . . $358
Filling (4 Surfaces) . . . . . . . . . . . . $340 . . . . . . . . . . . . $425
Crown . . . . . . . . . . . . . . . . . . . . . $1,116 . . . . . . . . . .$1,396
Implant Crown . . . . . . . . . . . . . . $1,436 . . . . . . . . . .$1,795
Crown Buildup . . . . . . . . . . . . . . . $271 . . . . . . . . . . . . $339
Root Canal (Molar) . . . . . . . . . . . $979 . . . . . . . . . . .$1,224
Root Canal (Anterior) . . . . . . . . . $714 . . . . . . . . . . . . $893
Denture (Maxillary) . . . . . . . . . . $1,743 . . . . . . . . . . .$2,179
Denture (Mandibular) . . . . . . . . $1,743 . . . . . . . . . . .$2,179
Extraction . . . . . . . . . . . . . . . . . . . $150 . . . . . . . . . . . . $354
Restorative Dentistry
Service Co-Payment“Basic Care”
Regular Feesas High as
Soft-Tissue Management . . . . . . . $193 . . . . . . . . . . . . $301(per quadrant)
Periodontal Maintenance . . . . . . $109 . . . . . . . . . . . . $170
Laser Therapy . . . . . . . . . . . . . . . . .$40 . . . . . . . . . . . . . . $50(every six months)
Periodontics
Service Co-Payment“Basic Care”
Regular Feesas High as
Nightguard . . . . . . . . . . . . . . . . . . $299 . . . . . . . . . . . . $791
Traditional Braces . . . . . . . . . . . $4,300 . . . . . . . . . . .$5,934
Orthodontics
Service Co-Payment“Basic Care”
Regular Feesas High as
Cosmetic Consultation . . . . . .No Charge . . . . . . . . . . . $95
Cosmetic Whitening . . . . . . . . . . $249 . . . . . . . . . . . . $500
Emergency Exam . . . . . . . . . . .No Charge . . . . . . . . . . $194(limited exam)
Other Treatments
Service Co-Payment“Basic Care”
Regular Feesas High as
TDRTEXAS DENTAL
RESOURCES
xxx xx
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1-877-617-23201-817-605-6297(fax)
P.O. Box 54876, Hurst, TX 76054TexasDental.org
