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Earl L. Estwick, D.M.D., P.C.Bard Professional Bldg.
446 Route 304Bardonia, NY 10954
(845) 623 - 4887www.estwickdental.com
Please List AllUnmarried
Children Up to Age 20
1. Child’s First Name ____________________
Last Name __________________________
Middle Initial _____________ Son/ Daughter
Date of Birth ________________________
2. Child’s First Name ____________________
Last Name __________________________
Middle Initial _____________ Son/ Daughter
Date of Birth ________________________
3. Child’s First Name ____________________
Last Name ___________________________
Middle Initial _____________ Son/ Daughter
Date of Birth ________________________
4. Child’s First Name ____________________
Last Name __________________________
Middle Initial _____________ Son/ Daughter
Date of Birth ________________________
5. Child’s First Name ____________________
Last Name __________________________
Middle Initial ______________Son/ Daughter
Date of Birth ________________________
In - OfficeSavings Plan
Earl L Estwick, D.M.D., P.C.
It’s a savings plan for all services,
only good at Earl L. Estwick, D.M.D., P.C.You save on everything from
cleanings & fillings to cosmeticprocedures & crowns!
-No deductibles!
-No annual maximum
-Cosmetic dentistry is included!
-
Earl L. Estwick, D.M.D., P.C.Bard Professional Bldg.
446 Route 304Bardonia, NY 10954
(845) 623 - 4887www.estwickdental.com
Join Today!Join Today!
In - OfficeSavings Plan
MEMBER CARD
Patient Name
Plan Type:
Effective Date:Dr. Earl L Estwick446 Route 304 Suite CBardonia, NY 10954(845) 623-4887
"
Money Order
Visa / MasterCard / American Express / Discover
Credit Card #
Signature
Method of Payment
Exp. date
Check
Composites-Anterior $100/$176 $125/$220Composites-Posterior $100/$188 $125/$235*Ceramic Crown $800 $1000*Veneers (per tooth) $840 $1050*Lab Fee not included
Root Canal $720 $900
*Complete Upper Denture $1080 $1350
Zoom Whitening $400 $500
Restorative Dentistry*
Service Cost Reg. Fee
Endodontics*
Dentures*
Other Treatments*
Make check payable to Earl L Estwick, D.M.D., P.C.
Savings of 20% off our regular fees.* Prices subject to change
Our in office savings plan is an easy-to-use alternative to dental insurance plans for individuals and families. Join the plan today and enjoy on the spot savings of 20% on most dental care procedures including cosmetic dentistry.
Individual— $199/yr.
Individual & Spouse— $299/yr.
Family Plan—$399/yr.
(two adults & two children)
Additional Child in Family—$79/yr.
Join Today,Save Today!
First Name________________________________
Last Name________________________________
Middle Initial____________________Female/ Male
Home Address _____________________________
________________________________________
City ________________State______ Zip ________
Phone ___________________________________
Email ____________________________________
Date of Birth ___/___/___ S.S.# ____-____-______
Spouse First Name __________________________
Last Name ________________________________
Middle Initial____________________Female/ Male
Enrollment Period ____________ to ____________
Signature (member & spouse)
_________________________Date____________
_________________________Date____________Service Cost Reg. Fee
Service Cost Reg. Fee
Service Cost Reg. Fee
*Lab Fee not included
Extraction $168 $210
Patients agree that Earl L. Estwick, D.M.D., P.C. fees stated must be paid at the time services are rendered. Non-refundable plan fees are valid only when paid at the time of enrollment. All family members must reside in the same household. This is not an insurance product.
Preventive Dentistry*
Service Cost Reg. Fee
Oral Examination (every 6 months ) No Charge $404 Bitewings (every 12 months) No Charge $55Adult Prophylaxis (every six months) No Charge $90Children’s Prophylaxis (every six months) No Charge $70Fluoride Treatment for up to age 13 (every six months) No Charge $40
Examples of Savings
In - Office Savings Plan
In - Office Savings Plan
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