Dental Savings Plan

Burns Family Dentistry | Noblesville, IN

Dental Savings Plan

Fill out the form and submit it to our office electronically below. If you’d prefer, you can download and print the PDF here.

Our Dental Savings Plan is one (1) year contract, starting from the date of signed contract between patient and Burns Family Dentistry. This savings plan has been designed as a courtesy to help meet the needs of our patients that do not have the benefit of dental insurance.

Annual Membership Benefits Include:

  • -Two basic Dental Cleanings ( Adult or Child)
  • -Two Dental Examinations
  • -X-Rays ( Adult Four Bitewing x-rays, Child Two Bitewing x-rays)
  • -X-Rays (Adult & Child Two Periapical x-ray)
  • -Two Fluoride Treatments


  • -Adults (age 14 and older) = $295.00 (20% savings)
  • -Children (age 13 and younger) $260.00 (20% savings)
  • -Payment of the above fees will be due in full when contract is signed
  • -No refunds will be given on unused services
  • -Ten percent (10%) courtesy discount on all other services provided at Burns Family Dentistry. (Offer excludes bleaching and other dental products)


MM slash DD slash YYYY
MM slash DD slash YYYY
MM slash DD slash YYYY
MM slash DD slash YYYY
MM slash DD slash YYYY

I/we have read and understand the above contract and agree to all terms.

Printed Name(Required)
MM slash DD slash YYYY

Burns Staff: __________________________________________

Date: ________________________