In exchange for agreed upon fees paid by Patient(s) or a representative of the Patient(s), the Practice agrees to provide the Patient(s) Services described in this Agreement at the above address only, on the terms and conditions set forth in this agreement. As used in this Agreement, the term Services shall mean dental services which are offered by Cammellia Askari, DMD or Leyla Sahabi, DMD or another licensed dentist or dental hygienist.
Concierge Plan Selection
The patient should select only one of the following checkboxes denoting a selected plan and frequency of payment. If a Couple or Family plan is selected, the names of all individuals should be entered below. All plans include all preventative care at 100% coverage with no additional out-of-pocket expenses. Preventative care is defined as two cleanings, all exams, and unlimited, as needed x-rays as prescribed by the care provider at the above-mentioned location, per each 12-month period. There are also no annual maximum benefit amounts for any of the plans.