Legal & Disclaimers:

HealthSure is not insurance but a membership payment plan provided by Germantown Dental and is not transfwerable to other dental offices. Payment for any cosmetic or restorative treatment is due at the time of service. Membership dues must be current in order to receive plan benefits. It is soley the patient’s responsibility to schedule and keep their appointments. No refunds will be provided for dues paid under any circumstances, including failure to schedule and maintain appointments.

GERMANTOWN DENTAL

HEALTHSURE PLAN

“Dr. Kellum and staff

are so friendly &

professional.

They do an amazing

job and are always

happy to

accommodate.

I would highly

recommend.”

Leah L.

Germantown Dental 1324 4TH Avenue N. Nashville, TN 37208

615.742.5578 www.germantown.dental

drkellum@germantown.dental

Receive All the Rewards of Dental Insurance Without the Hassle.

No Deductibles

No Yearly Maximum Benefits

No Exclusions for Cosmetic

or Elective Care

HealthSure Member Advantages:

Complimentary Preventative Care: Cleanings, Exams, Fluoride Treatments, X-Rays

20% Discount All restorative, elective or cosmetic treatment

Easy & Affordable

HealthSure Plans Adult Preventative

$285/year (Save $300/year) • Professional Dental Cleanings (2/yr.)

• Doctor Exams (1-2/yr.)

• Needed X-Rays

• All Emergency Exams Needed

• Fluroide Treatment

• 20% Off All Other Dental Services (Including Cosmetic Procedures)

For patients of regular cleanings and an absence of periodontal disease.

Adult PerioCare $400/year (Save $600/year)

• Perio Maintenance Cleanings (3-4/yr.)

• Doctor Exams (1-2/yr.)

• Needed X-Rays

• All Emergency Exams Needed

• Fluroide Treatment

• 20% Off All Other Dental Services (Including Cosmetic Procedures)

For patients enrolled in active periodntal maintenance due to prior treatment of periodontal (gum) disease.

Child Preventative $235/year (Save $270/year) • Professional Dental Cleanings (3-4/yr.)

• Doctor Exams (1-2/yr.)

• Needed X-Rays

• All Emergency Exams Needed

• Fluoride Treatment

• 20% Off All Other Dental Services (Including Cosmetic Procedures)

READY TO JOIN? Fill out the form below:

Call our office at 615.742.5578 to enroll or schedule an appointment.

Members Joining: Name: _____________________ DOB __ / __ / __

Adult Adult PerioSure Child

Name: _____________________ DOB __ / __ / __

Adult Adult PerioSure Child

Name: _____________________ DOB __ / __ / __

Adult Adult PerioSure Child

Name: _____________________ DOB __ / __ / __

Adult Adult PerioSure Child

Responsible Party: Name: ________________________________

Date of Birth _____ / ______ / _______

Email: ________________________________

Phone: ___________________________

For Office Use: Membership Plan: _____________________

Start Date: _____________________________

Expiration Date: _____ / ______ / _______

Patient Signature: ______________________

Office Signature: _______________________