2024-2025 Dental Membership Plan Enrollment Form

Aesthetic Dentistry of Bend is pleased to offer a Dental Membership Plan.  You will save on everything from cleanings and fillings to cosmetic procedures and crowns.

patient forms

Benefits per year:

Two Routine Exams ($69 each)

One Emergency Exam ($93)

Two Standard Cleanings (in the absence of active periodontal disease) ($127 each)

Full Mouth X-rays, Bitewing X-rays, or Panoramic X-ray (FMX $159, BW $89)

Two Fluoride Varnish Treatment ($45 each)

(savings of $375 for the year on your recare/preventative services!)

20% off Aesthetic Dentistry of Bend fees for all Dental Services


Periodontal Maintenance Therapy Inclusions: (in addition)

  • Three periodontal maintenance cleanings
  • Two gingival irrigation/quad


Membership Plan Advantages:

  • No yearly maximum
  • No deductibles
  • No claim forms
  • No pre-authorizations
  • No pre-existing condition limitations
  • No one will be denied coverage
  • No waiting periods (immediate eligibility)


Yearly Membership Costs:

Child Membership (12 years old and younger) $279/year

Adult Membership (13 years old and up) $369/year

Active Periodontal Therapy/Periodontal Maintenance add $180 for year- 3 cleanings a year ($549)


Program Exclusives and Limitations:

• This is NOT a dental insurance. This is an in-house dental membership plan that is ONLY good at

Aesthetic Dentistry of Bend.

It CANNOT be combined with any other dental insurances or financing programs.  

• Membership premium is due at the time of the first exam.

• All payments are non-refundable. No refunds of premiums will be issued at any time if participant

decides not to utilize plan.

• All financial terms of Aesthetic Dentistry of Bend are applicable to the membership plan.

• The two cleanings included in this plan are standard cleanings. Should you need periodontal

maintenance, you will have 3 of these cleanings covered under the plan. The additional periodontal

maintenances will be a fee of $140 added to annual fee, if diagnosed or currently on periodontal

maintenance therapy.

If you are diagnosed with active periodontal disease, that will require scaling and root planing, this will

not be considered as a “standard cleaning,” but will be discounted under the dental plan for treatment.

• All discounts are available solely through Aesthetic Dentistry of Bend.

• Missed or broken appointments without 24-hour notice will be subject to missed appointment fee of $50.

• Memberships will renew on the anniversary date until cancelled in writing, unless approved by Aesthetic Dentistry of Bend

• 30 days written notice of cancellation is required to cancel the membership plan.

Membership fees and plan discounts are subject to change on an annual basis.

Aesthetic Dentistry of Bend reserves the right to cancel or discontinue this plan for any reason at the end of the membership term.

  • Can not be used on referred services to other offices or hospital visits, or workers compensation insurance claims.
  • These guidelines and fees subject to change at any time.

• Membership services are used or lost, they are not carried over.

• The plan is valid for one year from the date this is signed and premium is paid.

This plan is only honored at Aesthetic Dentistry of Bend, It cannot be used at any other dental office.