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Concierge Practice Patient Agreement

Newbury Dental

1443 Leimert Boulevard,
Oakland, CA, 94602
5104825300

( * mandatory to fill )

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.

**SELECT ONLY ONE OPTION BELOW

1. Essentials

20% Off All Other Care*

5% Off Cosmetic, Implant & Invisalign

  •  $29/month
  •  $329/year
  •  $55/month
  •  $649/year
  •  $85/month
  •  $999/year

2.Premium

30% Off All Other Care*

10% Off Cosmetic, Implant & Invisalign

  •  $49/month
  •  $575/year
  •  $95/month
  •  $1,099/year
  •  $139/month
  •  $1,625/year

3. Platinum 

50% Off All Other Care*

15% Off Cosmetic, Implant and Invasilgn

  •  $149/month
  •  $1,749/year
  •  $289/month
  •  $3,449/year
  •  $439/month
  •  $5,199/year

*The denoted discounts for each plan are given off of the Practice Usual and Customary and Reasonable (UCR) fee schedule. All Standard Care includes all care that is non-cosmetic and not related to orthodontics (Invisalign) or implant procedures.

**Family includes the Patient, the Patient’s spouse or domestic partner and up to two (2) minors.

If you have selected a couple or family plan, please include the name(s) of the additional enrollees in the box below, separated by commas. Family plans may include one spouse or domestic partner and up to two minors. 

Payment and Cancellation

The initial monthly or the entire annual fee for the first year is payable upon execution of this agreement in the form of check or credit card. By executing this agreement, you agree to commit to at least 12 months as enrollee(s) in the plan you select. The 12-month commitment automatically renews each year on the anniversary date of this agreement. You also agree that you will provide a form of payment at the time of the execution of this agreement (either a credit card or a checking account) and that your bank account or credit card will be debited/charged on a monthly or annual basis (depending on the plan selection) in perpetuity for the agreed upon amount until you provide a written notice of cancellation. At any given time, the Practice requires 21 days of notice before cancelling your enrollment. Cancelling a monthly plan before the end of your current 12-month cycle will result in a charge of your credit card or bank account for [number of remaining months of the current cycle] * [your monthly fee] OR the total of non-discounted UCR fees for all procedures, including cleanings, xrays and exams, completed during the current 12-month cycle minus the paid portions, whichever is less. The fees are locked for the 12-month period in which you are currently enrolled, but may increase for the following 12-month period, in which case the patient will be notified. You will be responsible for all overdue fees if a credit card or bank account number gets declined or expires and a new number is not provided by you. You cannot downgrade your plan before your current cycle expires. You can upgrade your plan at any time which will reset your term from the date that you upgrade.

  •  Credit Card
  •  Checking Account

Insurance

Patient acknowledges that the Askari and Sahabi Dental Partnership participates in limited dental/health insurance plans. Fees paid under this Agreement are not covered by your dental/health insurance or other third-party payment plans applicable to the Patient. The Patient shall retain full and complete responsibility for any such determination. Patient further acknowledges and understands that this agreement is not an insurance plan and not a substitute for dental/health insurance or other health plan coverage. It will not cover hospital services or any services not personally provided by Askari and Sahabi Dental Partnership. Patient acknowledges that Askari and Sahabi Dental Partnership has advised that patient obtain or keep in full force such health insurance policies or plans that will cover Patient for general healthcare costs. Patient acknowledges that this Agreement is not a contract that provides health insurance and is not intended to replace any existing or future health/dental insurance or dental plan coverage that Patient may carry.

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