Tooth Club Berkhamsted – Implant Service Plan

All Instructions are supported by the Direct Debit Guarantee. In order to set up a Direct Debit online you must be the account holder of a personal or business bank or building society account.

Name: Tooth Club

Address: 207-209 High Street, Berkhamsted, Herts, HP4 1AD

Telephone: 0333 2419130

Plan Specifics - Implant Service Plan - £23.95 per month

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I am an existing patient

I am a new patient

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I would like to add Worldwide Accident & Emergency cover for 85p per month

I would NOT like to add Worldwide Accident & Emergency cover

Office Use Only - Staff Member Name

Office Use Only - Dentally ID

Contact Information

Name(Required)

Title First Name Surname

Date of birth(Required)

Address(Required)

Street Address Address Line 2 City Postcode

Telephone Number(Required)

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TERMS AND CONDITIONS: There is a one off £10 joining fee which will be payable with your first monthly payment. Your payments are taken on the 1st working day of each month. If the 1st of the month is unsuitable we can take your payment on the 15th working day of the month. Our membership plans are for a minimum of 12 months, and after that the plan renews automatically on a rolling monthly basis. Should you cancel the plan before you have made 12 monthly payments, any treatment that you have had under the plan will become payable on cancellation if your payments that you have made do not cover this. You are entitled to the benefits of the plan as soon as you have signed up and we have received confirmation from Smilecare, our plan administrators, that this has been done. You are responsible for making your appointments and attending them, you will not be refunded if you do not make your appointments in your plan. Should you also fail to cancel a plan appointment within our cancellation policy of 48 hours, you will forfeit that benefit (eg you miss a hygiene appointment and give less than 48 hours notice so you lose that hygiene appointment). Any benefits you do not use in the year are not carried forward.

DATA PROTECTION: The information on this form contains your personal data. Smilecare Limited processes and holds your personal data on behalf of the practice in accordance with the General Data Protection Regulation 2018 (GDPR). Your personal data will only be used by Smilecare Limited in the administration of your dental plan and for no other purpose and by no third party.

DEMANDS AND NEEDS STATEMENT: The Supplementary Insurance policy is designed to meet the demands and needs of patients who require insurance cover for treatment costs arising from dental injury or emergency. The policy is an add on to your dental plan, and is not mandatory. No recommendation has been made in connection with this insurance policy. If you wish to remove the insurance at anytime please contact Smilecare. This will reduce your monthly payments by £0.85 if you opted in beforehand

DECLARATION: I am a patient of Tooth Club and request Smilecare Ltd to collect direct debits as detailed above. I understand that Smilecare Ltd (on behalf of Tooth Club) is the administrator of the payment scheme and the responsibility for my dental care remains with my dentist. I confirm that I have read and now fully understand the explanatory brochure and the Supplementary Insurance Policy.

I understand that the plan is for a minimum of 12 months and will continue to roll month on month thereafter until cancelled. I understand that I must inform Smilecare Limited of any changes to personal details and if I wish to cancel the plan.

Payment Information

Admin discount code

Registration Fee: £10.00

Direct Debit Monthly Fee: £23.95

Your payment will be taken on the first working day of the following month.

Instruction to your Bank or Building Society to pay by Direct Debit

Account holders name(Required)

Account number(Required)

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Bank or Building Society Name(Required)

Bank or Building Society Address(Required)

Street Address Address Line 2 City Postcode

The Direct Debit Guarantee

This Guarantee is offered by all banks and building societies that accept instructions to pay Direct Debits
If there are any changes to the amount, date or frequency of your Direct Debit SMILECARE LTD will notify you 10 working days in advance of your account being debited or as otherwise agreed. If you request SMILECARE LTD to collect a payment, confirmation of the amount and date will be given to you at the time of the request
If an error is made in the payment of your Direct Debit, by SMILECARE LTD or your bank or building society, you are entitled to a full and immediate refund of the amount paid from your bank or building society. If you receive a refund you are not entitled to, you must pay it back when SMILECARE LTD asks you to.
You can cancel a Direct Debit at any time by simply contacting your bank or building society. Written confirmation may be required. Please also notify us.