Please fill out and send thisform in today to enroll!

Please List All UnmarriedChildren up to Age 21

1. Child’s first name ___________________________Middle initial ________________ Son / DaughterDate of birth _______________________________

2. Child’s first name ___________________________Middle initial ________________ Son / DaughterDate of birth _______________________________

3. Child’s first name ___________________________Middle initial ________________ Son / DaughterDate of birth _______________________________

4. Child’s first name ___________________________Middle initial ________________ Son / DaughterDate of birth _______________________________

5. Child’s first name ___________________________Middle initial ________________ Son / DaughterDate of birth _______________________________

Our Affordable CoverageIncludes the FollowingServices at No Charge:

• Comprehensive Exam(Once every six months)• Fluoride Treatment for Children(Under the age of 18, once every six months)• Bitewing X-Rays(Once every twelve months)• Cleaning (Prophylaxis)(Once every six months, twice per calendar year)

Enroll Today!Join Dr. Grucella’s

In-House Dental CoverageIt’s a discounted fee schedule for most services, only good

at Dr. Grucella’s office. You save on everything from cleanings and fillings to cosmetic procedures and crowns!

• No Deductibles• No Maximums• No Waiting Periods• No Health Questions• No Pre-Determinations• You Cannot Be Denied Coverage• Pre-Existing Conditions Are Covered• You Cannot Be Singled Out for Rate Increases

Dr. Grucella Voted Best Dentist 8 Years in a Row

Fairlawn620 Ridgewood Crossing Drive

330-733-7911

Lakemore/Springfield1500 Canton Road330-733-7911

Canton4227 Tuscarawas Street West

330-454-7700

Dr. Grucella’s AffordableDental Plan Can Help

GGDentist.com

No Insurance?No Problem

Dr. Grucella with patients Tim and Jen

Start Saving Today

Low Cost Dental CoverageNow you can join our low-cost dental plan for a

nominal 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 and return it with your check, money order or credit

card information. Please make checks or money orderspayable to Family Dental Team, Inc.

Low-Cost Dental Coverage

• Individual – $150 / year• Individual and Spouse – $295 / year• Family Plan (two adults & two kids) – $425 / year• Additional Child in Family – $110 / year

Preventive Dentistry

Service Member Fees Regular FeesExamination No charge $50

(every six months)

Bitewing X-Rays No charge $60(every twelve months)

Adult’s Cleaning No charge $100(every six months)

Children’s Cleaning No charge $65(every six months)

Fluoride Treatment No charge $34(every six months)

20% Off Dental Services**Some Exclusions Apply

Please inquire about services not listed

Fillings (Composite/Tooth-Colored)Service Member Fees Regular Fees

One Surface $136 $170

Two Surfaces $172 $215

Three Surfaces $204 $255

Four Surfaces $240 $300

PeriodonticsService Member Fees Regular Fees

Root Planing & Scaling $192 $240(per quadrant)

Periodontal Maintenance $104 $130

OrthodonticsService Member Fees Regular Fees

MTM Clear Aligners $2880 $3200

Occlusal Guard $280 $350

Crowns and BridgesService Member Fees Regular Fees

All-Porcelain Crown $880 $1100(per unit)

Other TreatmentsService Member Fees Regular Fees

Implants (per tooth) $1530 $1700

Extraction (per tooth) $156 $195

Denture (per unit) $1196 $1495

Patients agree that Family Dental Team, Inc. feesstated must be paid at the time services are ren-

dered. Any service not paid for at the time ofservice will be billed at usual and custom-ary fees. Coverage fees are valid onlywhen paid at the time of enrollment. Ratesare subject to change annually. Member-

ship renews annually on the day and monthof initial enrollment. Notify office 30 days prior to

reenrollment date if you elect to cancel. Family DentalTeam, Inc. reserves the right to cancel a member’s enrollment. This plan is NON-trans-ferable. Cannot be used in any accident/injury case. All family members must reside inthe same household. This is not an insurance program. Family Dental Team, Inc. is nota licensed insurer, health maintenance organization, or other underwriter of health serv-ices. This plan may not be combined with any other offers, discounts, or advertisements.The discounts offered are valid only in this office and for services, not products.

Please fill out and send this form in today to enroll

First Name __________________________________Last Name __________________________________Middle Initial ____________________ Female / MaleHome Address __________________________________________________________________________City _________________ State _____ Zip _________Phone ______________________________________Email _______________________________________Birth Date ____ / ____ / ____ S.S.# ____ - ___ - _____Spouse First Name ____________________________Last Name __________________________________Middle Initial ____________________ Female / MaleBirth Date ____ / ____ / ____ S.S.# ____ - ___ - _____Enrollment Period ______________ - ______________Signature (member and spouse)______________________________ Date _______________________________________ Date _________

American Express / Discover / MasterCard / VisaCard Number _________________________________Expiration Date _______________________________

® Make check payable to Family Dental Team, Inc.