Dental Savings Plan Contract

Hall Family Dental Care Membership Plan

Jonathon C. Hall, DMD, LLC
3400 A Old Milton Parkway, Suite 540
Alpharetta, GA 30005

Hall Family Dental Care is pleased to offer our exclusive Dental Membership Plan. Please read the agreement carefully and let a team member know if you have any questions or concerns.

The Dental Membership Plan is not an insurance plan and is not intended to act as or replace dental insurance. For an annual renewable fee, our Dental Membership Plan will allow you to obtain many preventive services at no charge and significant discounts on other dental services.

With the Hall Family Dental Care Membership Plan you will have:

  • No waiting periods
  • No claim forms
  • No treatment restrictions (except as provided herein)
  • No pre-authorization requirements
  • No yearly maximums
  • No age limitations
  • No pre-existing condition exclusions

Included in the annual membership fee:

  • Two regular dental examinations per year
  • Two preventive prophylaxis (“cleaning”) procedures per year
  • Any radiographs (“x-rays”) associated with the preventive visits
  • Oral cancer screening
  • Oral hygiene instruction
  • One emergency office visit per year with any necessary radiographs (“x-rays”) – any treatment which may be deemed necessary as a result of the emergency will be offered at the discounted rate for Dental Membership Plan participants.
  • Two fluoride treatments per patient per year up until the patient reaches the age of 18
  • 15% discount on all other dental services when paid for at the time of service

Limitations and Exclusions of the Hall Family Dental Care Membership Plan:

  • Full-mouth rehabilitation
  • Worker’s compensation or employer’s liability treatment services
  • Third party products which are sold by the Practice
  • Cosmetic products and services
  • No additional discounts or coupons will be applied
  • Membership plan is non-transferrable

Please note:

  • This is an in-house Dental Membership Plan that is only valid at the office of Hall Family Dental Care. It cannot be used at any other location and it cannot be combined with any other dental insurance.
  • Membership fees must be paid prior to the first exam or scheduled treatment.
  • All payments are non-refundable. Refunds for Membership fees will not be issued at any time if the participant does not fully utilize the plan or obtain services within the applicable time period.
  • Payment in full for any treatments rendered under the Membership Plan must be made at the time of treatment.
  • Extended payment plans, including third party financing plans, may not be used in conjunction with this Membership Plan.
  • The two cleanings included in this plan are for standard cleanings ONLY. Scaling and root planing treatment of periodontal (“gum”) disease is NOT included.
  • “Periodontal Maintenance“ visits are covered under the Dental Membership Plan at the regular plan discount as provided herein.
  • There may be a charge assessed for any missed appointments or appointments canceled without 48 hours’ notice which is not covered under the Membership Plan.
  • Membership fees, services, and plan discounts are subject to change on an annual basis.
  • Hall Family Dental Care reserves the right to cancel or discontinue this plan for any reason at the end of the Membership term.
  • Services not utilized may not be “rolled over” to the next year or transferred between family members, plan participants, or any other individual.

Please select membership type:

Single plan - $342

I agree to the terms and conditions contained herein. I acknowledge and agree that the Dental Membership Plan offered by Hall Family Dental Care is not an insurance plan, it is a membership plan offered to provide a discount for select services provided at Hall Family Dental Care offices ONLY.

  • First Name
  • Last Name
  • MI
  • Date
  • Print Name
  • Signature
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