Membership Program

In an effort to make quality dentistry more accessible to our patients, we are pleased to introduce the New Day Dentistry Membership Program (herein known as the "Program"). This Program includes several services at no additional cost and offers discounts of up to 40% to our uninsured patients and their families. We hope this helps you to receive the dental care you need and want! We encourage our patients to direct any questions regarding this Program to our administrative team.

By signing and accepting this agreement, you acknowledge that you have read and agree to the following:

1. The fee for this program is $399 per year per adult, or $275 per year for children 13 years of age and younger.
2. This fee will enroll one patient but may be purchased for all members of a family separately.
3. All fees are due at time of signing.
4. This Program entitles the member to the following services at any New Day Dentistry PLLC office in Colorado at no additional fee:
   • Two Free Examinations per membership year (CDT codes D0150, D0120, D0180, D0140).
   • One set of Free Bitewing x-rays per membership year (CDT Codes D0274 or D0272).
   • One Free Full Mouth Series or Panoramic X-ray every 3-5 membership years (CDT Codes D0210 or D0330)
   • Two Free Hygiene visits per membership year which may include ONE of the following:
     • Two free Prophylaxis Cleanings per membership year (standard cleaning, CDT code D1110, D1120)
     • One free Full Mouth Debridement (for patients needing more than a standard cleaning, CDT Code D4355) and one standard adult cleaning (CDT Code D1110) per membership year.
     • Two Periodontal Maintenance cleanings (when a patient has a history of Periodontal Therapy, CDT Code D4910) per membership year. Additional Periodontal Maintenance cleanings at a reduced fee.
   • One free Fluoride Varnish treatment per year for contracted children 13 years of age and younger.
   • Automatic enrollment in the reduced fee schedule titled "New"Day Dentistry Membership Program", which allows a 10-40% fee reduction on most services performed in any New Day Dentistry PLLC office in the state of Colorado.
5. Laser Therapy and Scaling and Root Planing (Periodontal Therapy, also knows as a "deep cleaning" or "SRP", CDT Code D4341, D4342) are not included as part of the Free Hygiene visit allowance. Program members needing Laser Therapy or Scaling and Root Planing will receive a reduced fee.
6. The Program and any fees quoted will expire one year from the Effective Date and may be renewed at any time thereafter. Any unused benefits will be lost on the Expiration Date. Failed, missed or cancelled hygiene and/or exam appointments without 2-business days' notice will be considered a utilized Free Visit.
7. Payment must be made at time of service for all treatment. Should additional, unplanned treatment become necessary, our office will require verbal (and often written) consent. Fees will be discussed in advance whenever possible.
8. Any fees quoted are applicable to work performed by a New Day Dentistry PLLC dentist or dental care provider only. Members who are referred to a non-affiliated specialist will be responsible for the specialist's fees.
9. All Program and treatment fees are non-refundable upon signing of this agreement. Program benefits are non-transferable and cannot be shared or sold. Standard Fees will be made available to enrolling members for comparison by request.

My signature below indicates that I have read, understand and agree to the above and would like to enroll in The New Day Dentistry Membership Program. I understand that this is not an insurance plan and can only be used within participating New Day Dentistry PLLC locations in the state of Colorado. I was given the opportunity to ask questions and have had them answered sufficiently.