By signing below, I understand that I am enrolling myself and any designated dependents into Coast Dental’s discount dental plan, Smile Plus®. I acknowledge that Smile Plus is an exclusive program unique to Coast Dental and can only be used for services at a Coast Dental office. I understand that Smile Plus is a discount dental plan and is NOT A REGISTERED DENTAL INSURANCE PLAN. As a result, I will incur out-of-pocket expenses which are due to the provider at the time services are rendered.

I also understand the dentist(s) I select as my provider(s) may not perform all of the services listed on the fee schedule. I authorize the dentist who renders services to me, or members of my family under the Smile Plus program, to make available to Coast Dental Services, Inc. my dental records, photocopies or information regarding such services to the extent permitted by law. I understand that once my enrollment is complete, I am immediately eligible to receive Smile Plus benefits.

Terms and Conditions. This site and related services are provided subject to my compliance. My continued use of this site indicates that I agree to be bound by the Terms and Conditions of Use. If I do not agree to be bound by the Terms and Conditions of Use, I will exit this site promptly. Coast Dental Services, Inc. may revise and update the Terms and Conditions of Use at any time. It is my responsibility to review the terms, conditions, and privacy statements posted on the Coast Dental Services, Inc. website each time I enter the site. Continued use of the Coast Dental Services, Inc. website or Coast Dental Services will be considered as acceptance of any changes to the Terms and Conditions. Certain provisions of the Terms and Conditions may be superseded by expressly designated legal notices or terms on particular pages at this site.

1. Binding Agreement. Electronic information. I hereby consent to the exchange of information and documents electronically over the Internet or by e-mail, and I understand that this electronically displayed information shall be the equivalent of a written paper agreement. I have the right to receive this agreement in non-electronic form and I may request a non-electronic copy of this agreement either before or after I accept the terms of this agreement. To receive a non-electronic copy of this Agreement, please contact us at Coast Dental.
2. Payment of Fees. THE PATIENT AND ANY OTHER PERSON RESPONSIBLE FOR PAYMENT HAS THE RIGHT TO REFUSE TO PAY, CANCEL PAYMENT, OR BE REIMBURSED FOR A PAYMENT FOR ANY OTHER SERVICE, EXAMINATION OR TREATMENT WHICH IS PERFORMED AS A RESULT OF AND WITHIN 72 HOURS OF RESPONDING TO THE ADVERTISEMENT FOR THE FREE, DISCOUNTED FEE, OR REDUCED FEE SERVICE, EXAMINATION OR TREATMENT. ADDITIONAL CHARGES MAY BE INCURRED FOR RELATED SERVICES WHICH MAY BE REQUIRED IN INDIVIDUAL CASES. The dentists and hygienists are employees or independent contractors of Coast Dental, P.A., Coast Florida, P.A., Coast Dental of Georgia, P.C. Adam Diasti, DDS, DN 12490 (FL) DN 11634 (GA)

I understand that I may cancel Smile Plus membership within 30 days of enrollment with a written notice of cancellation to Coast Dental if I have not used any Coast Dental services.