Dental Hygiene Plan. For better oral health, fresh breath and a bright smile

Transcription

1 Dental Hygiene Plan For better oral health, fresh breath and a bright smile

2 Regular dental hygiene is essential for a healthy smile With the Dental Hygiene Plan your regular private hygiene visits can be paid for in convenient monthly instalments You can still pay for dental examinations and treatments in your usual way Join the Dental Hygiene Plan today to: Keep your breath fresh and your teeth looking their best Maintain health of your gums Save up to 10% on your hygiene fees Spread the cost of your hygiene care Save 10% on oral hygiene products such as toothbrushes and floss Choose optional dental accident and emergency cover Speak with a team member to choose the best plan for your needs with options from one to four treatments per year: HYGIENE ONE: Includes one dental hygiene appointment per year HYGIENE TWO: Includes two dental hygiene appointments per year HYGIENE THREE: includes three dental hygiene appointments per year HYGIENE FOUR: includes four dental hygiene appointments per year

3 Join the Dental Hygiene Plan today for fresh breath and a healthy smile Why visit a hygienist? Dental hygienists work with your dentist helping you to maintain a healthy mouth and smile by preventing and treating gum disease and promoting good oral health Can hygienists help with bad breath? Yes, they can discuss the possible causes and the treatment options They will show you how to achieve a healthy, clean mouth to help restore your confidence and smile How do hygienists help with bleeding gums? They will carry out any necessary scaling and polishing and show you how to prevent gum disease with oral hygiene at home Dental accident and emergency cover Plan members can choose dental accident and emergency cover for just 0.97p per month. For full terms and conditions see Join the Dental Hygiene Plan today to start saving immediately

4 Dental Hygiene Plan Agreement BETWEEN THE DENTAL SURGEON AGREEMENT START DATE 0 1 M M 2 0 Y Y Backdated Dr/Mr/Mrs/Ms/Other Practice name Address Town Postcode AND THE PATIENT/PAYER WHO IS THE CONTRACT HOLDER Title Mr/Mrs/Other Date of birth D D M M Y Y Y Y Gender M F Address Town Postcode Telephone Monthly fee The following group members are included in this plan Mr/Mrs/Other Date of birth D D M M Y Y Y Y Gender M F Monthly fee Mr/Mrs/Other Date of birth D D M M Y Y Y Y Gender M F Monthly fee Mr/Mrs/Other Date of birth D D M M Y Y Y Y Gender M F Monthly fee If you have more than 4 in your group please use another form Please note that there is a one off 5 joining fee collected with the first payment. For details of the Dental Accident and Emergency Insurance cover please see codeplan.co.uk/cover

5 Method of Payment - Direct Debit I accept this agreement: Patient/Payer s signature Date D D M M Y Y Y Y Signed for and on behalf of the Dental Surgeon Date D D M M Y Y Y Y Data Protection Act: your data will be kept confidential but we may send it confidentially to other companies for processing payments or correspondence about your membership. By signing this Agreement you are consenting to such use of personal details. INSTRUCTION TO YOUR BANK OR BUILDING SOCIETY TO PAY BY DIRECT DEBIT Name and address of your Bank or Building Society To the manager Address Name(s) of account holder(s) Postcode Bank/Building Society Branch sort code Reference number Originators identification number Bank account number (office use only) Instructions to your Bank or Building Society: Please pay the CODEplan Ltd Direct Debits from the account detailed in this instruction subject to the safeguards assured by the Direct Guarantee. I understand that this instruction may remain with CODEplan Ltd and if so details will be passed electronically to my Bank/Building Society. Patient/Payer s signature Date D D M M Y Y Y Y THE DIRECT DEBIT GUARANTEE This guarantee is offered by all Banks and Building Societies that take part in the Direct Debit Scheme. The efficiency and security of the Scheme is monitored and protected by your own Bank or Building Society. If the amounts to be paid or the payment date changes, CODEplan will notify you 5 working days in advance of your account being debited or as otherwise agreed. If an error is made by CODEplan or your Bank or Building Society you are guaranteed a full and immediate refund from your branch of the amount paid. You can cancel a Direct Debit at any time by writing to your Bank or Building Society. Please also send a copy of your letter to us. Please complete this form, detach it and post it to: CODEplan, Elm Tree House, Bodmin Street, Holsworthy, Devon, EX22 6BB

6 CODEplan Ltd administers the collection of subscriptions on our behalf see codeplan.co.uk, CODE is a trading name of CODEplan Ltd.