Teeth Whitening for Life Agreement Activation

 Teeth Whitening for Life Agreement
Free Professional Teeth Whitening for Life is a program that Sage Dental Care is very pleased to offer to our patients. We feel
this is a great value that we hope serves an incentive for our patients to commit to prevention as part of their oral health. To
qualify and stay in the program, you must: 1) keep your regular cleaning appointments, which are the foundation of a great oral
health program and 2) get the minimum necessary dental work done that is recommended by our dentists at each of your
appointments to maintain healthy teeth and gums.
As a participant in the program, you will receive free professional grade whitening gel and custom made, take home whitening
trays for your personal use. To qualify for and remain in the program, there are some other rules that we ask that you follow.
Please take the time to read the policies and sign below to indicate that you understand and agree to them. If you don’t follow the
rules, you will be disqualified from the program until you have met all of the qualifications again for a minimum of 12 months.
Since keeping your appointments is critical to staying in the program, we will also ask that you comply with our Broken
Appointments Policy, which will be provided to you as well.
Activation Rules
For New Patients:
• You must be at least 18 years of age.
• The first step is to complete initial teeth cleaning by
one of Sage Dental Care’s hygienists. This
appointment must also include x-rays, doctor’s exam,
and the confirmation of the next hygiene appointment
for re-care (in six months).
• You must comply with minimum required dental care
as treatment planned by doctor*.
• You will adhere to our broken appointment policy.
• Your account must be kept current, with no
outstanding bills with Sage Dental Care.
For Existing Patients:
• You must be 18 years of age or older.
• We ask that you comply with minimum required
dental care as treatment planned by doctor*.
• You will adhere to our broken appointment policy.
• Your account must be kept current, with no
outstanding bills with Sage Dental Care.
• Must have at least a six-month patient history without
any broken appointments.
Upon your next appointment, you will receive Professional Teeth whitening package**
After all necessary dental treatment has been completed; patient will have impressions taken for professional whitening system.
Lifetime Maintenance Rules
1. We ask that you maintain the minimum continued care treatment as planned by your Sage Dental Care dentist. *
2. It’s important that you maintain regular six-month hygiene appointments.
3. You must comply with all Sage Dental Care policies for both payment and broken appointments.
One whitening solution refill will be rewarded at each re-care appointment, or twice annually. Additional whitening solutions may
be purchased for $15. Lost or destroyed applicator trays will be replaced at cost of $50 to patient.
* Patients will receive their whitening package once they have completed of all the necessary dental treatment as determined by a
Sage Dental Care dentist. If no dental treatment is performed, the total whitening package will be received when the patient
completes the follow-up visit (typically six months).
** New patient may activate “Free Professional Teeth Whitening for Life” membership upon first visit for 50% off our regular
whitening fee if the doctor determines the patient’s mouth is healthy.
Disclaimer: Sage Dental Care has the right to refuse offer if deemed necessary based on patient health conditions, misuse, or any
other factor deemed necessary to void offer.
I, ________________________________ hereby certify that I agree to the terms and conditions outlined above. I also
acknowledge receipt of Sage Dental Care’s Broken Appointment Policy. I understand that ‘Free Professional Teeth Whitening for
Life’ is a privilege offered only to individuals who meet and maintain all of the rules and regulations pertaining to the program.
__________________________________________________________
Signature
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Date