Dental Clinic Pro Toolkit
A complete toolkit for established dental clinics, including an annual care membership agreement and an in-depth orthodontic progress review
Get started with PocperA complete toolkit for established dental clinics, including an annual care membership agreement and an in-depth orthodontic progress review
Get started with PocperThis agreement sets out the terms of an annual dental care membership between the dental practice ("Practice") and the patient ("Member"). It is not dental insurance. It becomes effective only when BOTH parties have signed below. The Practice completes and signs the plan and fee details first, then shares this document with the Member for review and countersignature — either in-app, or by printing, signing, and uploading a scanned copy.
Practice (name / clinic name):
Member (full legal name):
Member email:
Membership start date:
Initial term:
During each year of the term, the Practice will provide the Member with the preventive care listed below:
Service | Included per year | Notes |
|---|---|---|
Any treatment not listed above — including restorative, emergency, or specialist care — is outside this membership and is quoted and billed separately under Section 4.
I have read and understand which services are included in my membership.
Item | Amount | Billing cycle |
|---|---|---|
Membership fee | ||
Member discount on additional treatment | ||
Late payment fee |
The membership fee is payable at the start of each billing cycle and is non-refundable once preventive care for that cycle has begun. Included visits have no cash value and cannot be exchanged for other treatment.
I have read and agree to the fee and payment terms in this section.
Treatment beyond the included preventive care is offered to the Member at the discount stated in Section 3. Any such treatment will be presented in a separate written estimate and must be approved by the Member before work begins. This membership does not oblige the Member to accept additional treatment.
I understand how additional treatment is estimated, discounted, and billed.
The Member agrees to give at least 24 hours’ notice to change or cancel an appointment. Included visits missed without adequate notice may be counted as used and are not carried over. A repeated pattern of missed appointments may, at the Practice’s discretion, lead to a fee or to non-renewal of this membership.
I understand the notice period and the consequences of missed appointments.
The Practice will keep the Member’s dental and personal records confidential and use them only to provide care, administer this membership, and meet legal obligations. Records are retained and shared in line with applicable data-protection and health-record laws. The Member may request access to their records at any time.
I consent to the collection and use of my records as described in this section.
After the initial term, this membership renews automatically for successive periods of the same length unless either party gives written notice of non-renewal at least 30 days before the current period ends. Either party may end this membership for material breach that remains uncured 14 days after written notice. On termination, the Member pays for any additional treatment already provided; membership fees already paid for the current cycle are not refunded.
I have read and agree to the termination and renewal terms in this section.
I have read and understood each section of this agreement.
I understand that this membership is not dental insurance.
I have had the opportunity to ask questions and seek independent advice.
I consent to electronic signatures having the same legal effect as handwritten signatures.
I am authorized to enter into this agreement on behalf of the party named above.
Practice — printed name:
Date:
Member — printed name:
Date:
Optional — upload a countersigned scan of this agreement:
This template is provided for reference only and does not constitute legal or dental advice. Consult qualified counsel before relying on this document.
The Annual Dental Care Membership Agreement template is a ready-to-use form from Pocper's Dental Clinic Pro Toolkit pack. Customize the fields to match your workflow, then share a link so clients can complete it and upload documents in real time.