AffordableDental Coverage

Low-Cost Dental CoverageAs Low as $22/mo.

Join Clocktower Family Dental’s In-House Premier Dental Coverage

• All Health Conditions Accepted!

• You Cannot Be Denied Coverage!

• No Deductibles!

• No Health Questions!

• You Cannot Be Singled Out for Rate Increases or Cancellations!

1. Child’s First Name _________________________ Middle Initial ______________ Son / Daughter Date of Birth ______________________________

2. Child’s First Name _________________________ Middle Initial ______________ Son / Daughter Date of Birth ______________________________

3. Child’s First Name _________________________ Middle Initial ______________ Son / Daughter Date of Birth ______________________________

4. Child’s First Name _________________________ Middle Initial ______________ Son / Daughter Date of Birth ______________________________

Complete This Form toBegin Coverage Today

Enroll Today!

As Low as $22/mo.

Please List All Children You Wish to Enroll

We are located in Castle Rock just off I-25 &

Founders Parkway.

ID# 5597 © November 2019 chrisad, inc., marin co., ca all rights reserved. 62672.

We’re Making Excellence in Dentistry Affordable for You!

718 Maleta Lane, Suite 101 & 102 Castle Rock, CO 80108

303-814-9899CastleRockDentist.com

• Comprehensive Exam (once every 6 months)

• Fluoride for Children (under the age of 18, once every 6 months)

• X-Rays (once every 12 months)

• Cleaning (Prophylaxis) (once every 6 months)

Our Affordable Coverage Includes the Following Services at No Charge:

Make your check or money order payable to Clocktower Family Dental.

Complete This Form toBegin Coverage Today!

Patients agree that Clocktower Family Dental fees stated must be paid at the time services are rendered. Any service not paid for at the time of service will be billed at usual & customary fees. Coverage 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. Membership renews annually on the day & month of initial enrollment. Membership renews automatically unless member formally requests otherwise in advance.

First Name ________________________________________

Last Name ________________________________________

Middle Initial ________________________ Female / Male

Home Address _____________________________________

__________________________________________________

City _____________________ State ______ Zip ________

Phone ____________________________________________

Email _____________________________________________

Date of Birth _____/_____/_____

Spouse First Name __________________________________

Last Name ________________________________________

Middle Initial ________________________ Female / Male

Date of Birth _____/_____/_____

Enrollment Period _______________ to _______________

Signature (member & spouse)

__________________________________ Date ___________

__________________________________ Date ___________

American Express / Discover / Mastercard / Visa

Card Number ______________________________________

Expiration Date ____________________________________

Please Inquire About Services Not Listed Here!

Low-Cost Dental Coverage Gold Plan Silver Plan

• Individual $528/yr. $264/yr.• Individual & Spouse $644/yr. $322/yr.• Family Plan $740/yr. $370/yr.

(two adults & two kids)

• Additional Child $20/yr. $10/yr. in Family

Now you can join our low-cost dental coverage for a nominal membership fee. Our coverage entitles you to preventive dental care at no cost! Corrective services are available for small co-payments that are far less than the usual, customary fees. Our professional staff is qualified to care for all of your dental needs!

To enroll, simply fill out the enclosed enrollment form & return it with your check, money order or credit card information. Please make your check or money order payable to Clocktower Family Dental.

Affordable Dental Coverage for the Whole Family!

Service Silver Plan Co-Payment

Regular Feesas High as

Gold Plan Co-Payment

Filling . . . . . . . . . . . . $227 . . . . . . . . . $302 . . . . . . . . . . . . . $377

Crown . . . . . . . . . . . $827 . . . . . . . . .$1,103 . . . . . . . . . . $1,378

Buildup . . . . . . . . . . . $158 . . . . . . . . . $211 . . . . . . . . . . . . . $263

Restorative Dentistry

718 Maleta Lane, Suite 101 & 102 Castle Rock, CO 80108

303-814-9899CastleRockDentist.com

Examination . . . . . . . . . . . . . . . . No Charge . . . . . . . . . . . .$119

X-Rays (every 12 months) . . . . . . No Charge . . . . . . . . . . . .$198

Adult Cleaning . . . . . . . . . . . . . No Charge . . . . . . . . . . . .$127 (every 6 months)

Children’s Cleaning . . . . . . . . . . No Charge . . . . . . . . . . . . .$93 (every 6 months)

Fluoride Treatment . . . . . . . . . . No Charge . . . . . . . . . . . . .$57 for Children (every 6 months)

Preventive Dentistry

Service Gold & Silver Plan Co-Payment

Regular Feesas High as

Service Silver Plan Co-Payment

Regular Feesas High as

Gold Plan Co-Payment

Cosmetic ConsultationNo Charge . . . .No Charge . . . . . . . . . $81

Cosmetic WhiteningNo Charge . . . .No Charge . . . . . . . . $759

Emergency Exam . . . . . $62 . . . . . . . . . .$82 . . . . . . . . . . . $102

Sealants (per tooth) . . . $45 . . . . . . . . . .$60 . . . . . . . . . . . . $74

Other Treatments

Nightguard . . . . . . . . $425 . . . . . . . . . $567 . . . . . . . . . . . . . $708

Traditional Braces . .$2,700 . . . . . . . .$3,600 . . . . . . . . . . $4,500

Clear Braces . . . $1,200–$2,400 . $1,600–$3,200 . $1,999–$3,999

Orthodontics

Service Silver Plan Co-Payment

Regular Feesas High as

Gold Plan Co-Payment

Periodontal Therapy . . . . . . . . . No Charge . . . . . . . . $273 (gum treatment, per quadrant)

Periodontics

Service Regular Feesas High as

Gold & Silver Plan Co-Payment