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Please List All Unmarried
Children Up to Age 20
As Low as
$229
Lakeville Rd
1. C
hild’s First Name __________________________
Middle Initial _______________
Son / Daughter
Date of Birth _______________________________
4. C
hild’s First Name __________________________
Middle Initial _______________
Son / Daughter
Date of Birth _______________________________
5. C
hild’s First Name __________________________
Middle Initial _______________
Son / Daughter
Date of Birth _______________________________
Our Affordable Plan Includes the
Following Services at No Charge:
• Comprehensive Exam
(once every six months)
• Fluoride Treatment
for Children
(under the age of 18,
once every six months)
• X-Rays
(once every 12 months)
• Cleaning (Prophylaxis)
(once every six months,
twice per calendar year)
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Marc
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LA
Fitness
e Park Rd
New Hyd
he
Nort
Please Fill Out & Send This
Form in Today to Begin Coverage!
3. C
hild’s First Name __________________________
Middle Initial _______________
Son / Daughter
Date of Birth _______________________________
$21
299
/yr.
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2. C
hild’s First Name __________________________
Middle Initial _______________
Son / Daughter
Date of Birth _______________________________
As
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Low-Cost Individual Dental Plan
Union
e
Turnpik
Sears
Our office is located one block west of
Lake Success Shopping Center. Free on-site parking!
Enroll Today!
Join Lake Success Dental Care’s
In-House Premier Dental Plan
It’s a discounted fee schedule for most services, only good
at Lake Success Dental Care. You save on everything from
cleanings & fillings to cosmetic procedures & crowns!
• All Health Conditions Accepted!
• You Cannot Be Denied Coverage!
Affordable
Dental Coverage
For You & Your Entire Family
A
Logo
Here
ffordable
Dental Coverage
For You & Your Entire Family
• No Deductibles!
• No Health Questions!
• You Cannot Be Singled Out for Rate Increases
or Cancellations!
1300 Union Turnpike, Suite 208
New Hyde Park, NY 11040
(516) 352-6777
www.LSDentalCare.com
ID# 3677 copyright © March 2014 chrisad, inc., marin co., ca all rights reserved.
We’re Making Excellence in
We’re Making Excellence in
Dentistry Affordable for You!
Dentistry Affordable for You!
Low-Cost Individual Dental Coverage
Now you can join our low-cost dental plan for a nominal
membership fee. Our plan 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 check or money orders payable to Lake Success
Dental Care.
Restorative Dentistry
Co-Payment
“Basic Care”
Service
Filling. . . . . . . . . . . . . . . . . . . . . . . $185 . . . . . . . . . . . . . $235
Crown. . . . . . . . . . . . . . . . . . . . . . $1,195 . . . . . . . . . . $1,495
• Individual ~ $229/yr. with Auto Payment
• Individual ~ $249/yr. without Auto Payment
Periodontics
Co-Payment
“Basic Care”
Co-Payment
“Basic Care”
Periodontal Maintenance . . . . . . . $170 . . . . . . . . . . . . . $215
Co-Payment
“Basic Care”
Regular Fees
as High as
Invisalign . . . . . . . . . . . . . . . . . . $5,494. . . . . . . . . . . $6,900
(financing available as low as $99/mo.)
City______________________ State _______ Zip _________
Phone _____________________________________________
Spouse First Name___________________________________
Last Name _________________________________________
Middle Initial_________________________ Female / Male
Date of Birth _____/_____/_____ S.S.# _____-_____-_____
Enrollment Period ________________ to ________________
Signature (member & spouse)
MasterCard / Visa / Discover / American Express
Card Number _______________________________________
Expiration Date _____________________________________
Other Treatments
Service
Co-Payment
“Basic Care”
Regular Fees
as High as
Cosmetic Consultation . . . . . . . . . $88. . . . . . . . . . . . . . $110
Children’s Cleaning. . . . . . . . . No Charge. . . . . . . . . . . $150
Cosmetic Whitening. . . . . . . . . . . $316 . . . . . . . . . . . . . $395
Fluoride Treatment . . . . . . . . . No Charge. . . . . . . . . . . . $75
for Children (every six months)
__________________________________________________
Make check payable to Lake Success Dental Care.
(every six months)
(every six months)
Home Address ______________________________________
__________________________________ Date ____________
®
Examination. . . . . . . . . . . . . . . No Charge. . . . . . . . . . . $125
Adult Cleaning . . . . . . . . . . . . No Charge. . . . . . . . . . . $150
Middle Initial_________________________ Female / Male
__________________________________ Date ____________
Orthodontics
Regular Fees
as High as
X-Rays (every 12 months) . . . . . No Charge. . . . . . . . . . . $125
Regular Fees
as High as
(per quadrant)
Service
Service
Last Name _________________________________________
Date of Birth _____/_____/_____ S.S.#_____-_____-_____
Soft-Tissue Management. . . . . . . . $260 . . . . . . . . . . . . . $325
Annual fee must be paid in full at time of registration.
Preventive Dentistry
First Name _________________________________________
Email______________________________________________
Service
Low-Cost Dental Plans
Regular Fees
as High as
Please Fill Out & Send This
Form in Today to Begin Coverage!
Emergency Treatment . . . . . . . . . . $175 . . . . . . . . . . . . . $220
Sealants (per tooth). . . . . . . . . . . . . $120 . . . . . . . . . . . . . $150
1300 Union Turnpike, Suite 208
New Hyde Park, NY 11040
(516) 352-6777
www.LSDentalCare.com
Please Inquire About
Services Not Listed Here!
Patients agree that Lake Success Dental Care 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. 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.