FOREVERWHITENING, exclusively offered by Advanced Dentistry of Collegeville
Advanced Dentistry of Collegeville’s Forever Whitening program is offered to our patients that show the greatest care for their teeth and oral hygiene. This program is our way of acknowledging the great care you take of your teeth and it is our privilege to be able to offer you this program for life! As with many great offers comes some rules that must be followed in order to stay in the Forever Whitening Program. Below you will find information about the program and the rules that you must follow to maintain the benefits of FOREVERWHITENINNG.
FOREVERWHITENING:
Program Fee: $250 (one-time fee)
Professional take home teeth whitening kit with applicator trays
1 free whitening syringe at each 6 Mo. Hygiene visit FOREVER
FOREVERProgram Initiation:
•Must be 18 years of age or older.
•Must complete an initial hygiene exam with our hygienist and doctor and receive treatment plan.
•Patient’s impressions will be taken for professional whitening trays (trays may take up to a week for delivery to our office).
•Must pre-book your hygiene appointments (3,4, or 6 month). If cancellation is necessary we must have 48 hour notice and you must re-book within two weeks of original appointment.
FOREVERMaintenance Rules:
•Must maintain treatment plan appointments as set by the doctor.
•Free whitening solutions (1 Syringe) will be provided at each 6 mo. hygiene visit or as otherwise noted by the Doctor.
•Must adhere to the cancellation rules stated above in program initiation
•Must maintain good payment status with Advanced Dentistry of Collegeville
•Lost or damaged applicator trays will be replaced at patient’s expense. $50
•Should any of the rules or qualifications be broken, you will be disqualified from the program. You will be given the opportunity to re-enroll if the reason for your dismissal has been rectified for a fee of $30
Disclaimer:
Advanced Dentistry of Collegeville has the right to refuse this program based on the patient’s’ health conditions, abuse or any other condition deemed necessary to void program offer. Patients that are suffering from gum disease, decay, root sensitivity, or oral cancers may not participate in our program until these problems are rectified and deemed safe by our doctor. We reserve the right to discontinue your enrollment in our Forever Whitening program at any time if the rules and acceptable hygiene are not maintained.
I certify that I acknowledge the FOREVERWHITENING program rules and regulations as stated above. I understand that FOREVERWHITENING is a privilege given to me by Advanced Dentistry of Collegeville and that I will maintain good oral health and maintenance to provide me a healthy and bright smile forever!
______
Patient Name (Please Print) Patient Signature Date