Practice Membership Info

Membership Agreement

Legacy Dental is pleased to offer an in-office membership plan to our patients who do not have dental insurance coverage. This plan allows patients to receive optimum dental care and maintain good oral health while saving money.

Annual Plan Benefits Include

Annual Plan Benefits Include

Paying for Your Membership

The Legacy Dental Membership Plan requires your payment in full. If you change your mind during the first 30 days you may cancel and pay our regular fees for services provided since joining the program After 30 days our memberships are nonrefundable.
Name
Address
I wish to enroll in the Legacy Dental Membership Program. I understand that dental services will be provided as described above. I understand that benefits not used cannot be transferred to the following year. It is my responsiblity to make my appointments. I also understand that cancellations without the proper notice and no show fees are to be paid by me as stated the practice policy and are not a benefit of this membership

Paying for Your Membership

The Legacy Dental Membership Plan requires your payment in full. If you change your mind during the first 30 days you may cancel and pay our regular fees for services provided since joining the program After 30 days our memberships are nonrefundable.
Name
Address
I wish to enroll in the Legacy Dental Membership Program. I understand that dental services will be provided as described above. I understand that benefits not used cannot be transferred to the following year. It is my responsiblity to make my appointments. I also understand that cancellations without the proper notice and no show fees are to be paid by me as stated the practice policy and are not a benefit of this membership

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