No Dental Insurance?We have a solution just for you.

“Dental Savings Plan”Look inside for details

Program Guidelines

This program is a discount plan, not a dentalinsurance plan. It cannot be used:

Program Exclusions & Limitations

Please ask one of our friendly front desk teammembers for an application or visit our website:

www.KatieToDDS.com

2 Exams per year2 Cleanings per year (absence of infection)

Patient’s portion of bill is due the day of service.There will be a $50 reinstatement fee if your plan lapses.Cannot be used in conjunction with another dental plan.CareCredit may not be used to pay a D$P premiumNo refunds of premiums will be issued at any time ifparticipant decides not to utilize dental plan.NON-REFUNDABLE.

D$P annual premiums must be paid with either cash, check or credit card.For treatment which, in the sole opinion of our doctorslies outside their scope.For referrals to specialists.For hospitalization or hospital charges of any kind.For costs of dental care which are covered under automobile medical.For services of injuries covered under workers’compensation.

This plan is only honored at Katie To, DDS.It cannot be used at any other dental o�ce.

www.KatieToDDS.com

(281) 392-8450

2910 Commercial Center Blvd.Suite 101, Katy TX 77494

Dr. Katie ToDr. Bar Nguyen

Our Dental $avings Plan is designedto provide greater access to qualitydental care at an affordable price.

Now WelcomingNew Patients!

Join Katie To, DDS In-House

It’s a discounted fee schedule for mostservices, only good at Katie To, DDS.

You will not be singled out for rate increases orcancellations. You will not receive a membership card.Your plan’s effective date will be on file with our office.

Dental $avings Plan

Auto Renewal Policy = 5% OFF!Sign up for auto-renewal of your dental savings plan

and receive 5% OFF next year’s premium!Ask our front desk team members how to

sign up for this great offer!

You save on everything from cleanings and fillingsto cosmetic procedures and crowns!

NO yearly maximumNO deductibleNO claim formsNO pre-authorization requirementsNO health questionsNO pre-existing condition limitationsNO one will be denied coverageNo waiting period (for major dental procedures)

Cosmetic dental procedures are includedFREE consultations

Dental $avings Plan

Coverage

Treatment: Member Discount:

Diagnostic and X-rays

Comprehensive Exam...........................................................100%(New patient / initial visit)

1 Annual Exam...........................................................................100%(Children under 18 = 2 per year)

1 Emergency Exam..................................................................100%(Annual or Emergency)

Complete Series X-rays or Panorex...............................100%(1 every 5 years)

4 Bitewing X-rays (1 time per year)..........................................100%Periapical, First Film...............................................................100%Periapical, Each Additional Film....................................100%

Preventive

Child Prophylaxis (2 cleanings per year).................................100%

Adult Prophylaxis (2 cleanings per year).................................100%

Fluoride (2 per year, no age limit)..................................................100%

Oral Cancer Screenings (2 per year).....................................100%

Additional Cleanings per year..............................................20%

Dental Sealants.............................................................................20%

All Other Procedures

Fillings................................................................................................20%

Oral Surgery....................................................................................20%

Root Canals......................................................................................15%

Crowns................................................................................................15%

Core Buildups.................................................................................15%

Periodontics.....................................................................................15%

Dentures and Partials................................................................15%

Implant Crowns.............................................................................15%

Whitening Procedures.............................................................20%

Invisalign®***.......................................................................$500 OFF

Braces***.................................................................................$500 OFF

Invisalign® Express (less than 6-months)***...$250 OFF

***An Invisalign member must remain a plan member for the durationof treatment to retain discount plan benefits.

Dental $avings Plan

BENEFIT PREMIUMS

Our Dental Savings plan for $365will include:

*The dual plan is for parent/child or husband/wife only.

**The family plan includes family members and children under 18 or children who are enrolled in college full-time until the age of 23.

1 Comprehensive Exam

1 Annual Exam

1 Emergency Exam (used any time during the year)

2 Cleanings (Prophylaxis or Periodontal Maintenance)

2 Oral Cancer Screenings

2 Fluoride Tooth Desensitizing Treatments

4 Bitewing X-rays

Any Individual X-rays needed throughout the year

Full Mouth Series of X-rays or Panorex

20% OFF Additional Cleanings, Dental Sealants,

Fillings, Oral Surgery, Whitening Procedures

15% OFF Crowns, Core Build Ups, Periodontics,

Root Canals, Dentures, Partials, Implant Crowns

$500 OFF Full Treatment Invisalign® or Braces

$250 OFF Invisalign® Express

PLAN TOTAL ANNUAL COST

Single $365 (savings of $385 off our normal fees)

Family** (4) $1241 (savings of $1,759 off our normal fees)

Family** (3) $985 (savings of $1,265 off our normal fees)

Dual* $699 (savings of $801 off our normal fees)

Each additional $149

Save over $1,400 compared to Average Dental Insurance/AARP in the first year!

Affordable Dental CoverageFor Your Entire Family!

Compare Out-of-Pocket Fees

Please ask one of our friendly front desk teammembers for an application or visit our website:

www.KatieToDDS.com

PLAN PREMIUM,PRODUCT OR

SERVICE

DENTAL $AVINGSPLAN

MEMBERSHIP

KATIE TO DDSREGULAR

PRICES

AVERAGE DENTALINSURANCE/AARP

COSTS

Annual Premium(single)

$365 $750 $600

$0 $0 $50

$0 $239 $0

$1241 $3,000 $2,250Annual Premium(Family of 4)

In officeZOOM

Whitening

$399(That’s 20% off!)

$499Not covered

by most plans

Cleaning, Exam,and Bitewing

X-Rays

Deductible

Patients agree that Katie To, DDS’s 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 and customary fees. Plan 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.