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Earl L. Estwick, D.M.D., P.C. Bard Professional Bldg. 446 Route 304 Bardonia, NY 10954 (845) 623 - 4887 www.estwickdental.com Please List All Unmarried 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 - Office Savings 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 cosmetic procedures & crowns! -No deductibles! -No annual maximum -Cosmetic dentistry is included! - Earl L. Estwick, D.M.D., P.C. Bard Professional Bldg. 446 Route 304 Bardonia, NY 10954 (845) 623 - 4887 www.estwickdental.com Join Today! Join Today! In - Office Savings Plan MEMBER CARD Patient Name Plan Type: Effective Date: Dr. Earl L Estwick 446 Route 304 Suite C Bardonia, NY 10954 (845) 623-4887 "

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Page 1: In - Office Savings Plan Earl L. Estwick, D.M.D., P.C.estwickdental.site/wp-content/uploads/2018/10/In... · * Prices subject to change Our in office savings plan is an easy-to-use

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

"

Page 2: In - Office Savings Plan Earl L. Estwick, D.M.D., P.C.estwickdental.site/wp-content/uploads/2018/10/In... · * Prices subject to change Our in office savings plan is an easy-to-use

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