Whitening for Life ProgramOptions For a Brighter, Whiter Smile for Life

1Level One 2Level Two 3Level Three

Basic Take HomeWhitening Kit

Custom Take HomeWhitening Trays

ProfessionalIn-Office Whitening

• Free to all patients

• Two week treatment

• One-size-fits-all gel tray

• Free syringe refills at cleaning visits

• Faster, professional results

• Customized, fitted gel trays

• Prescription strength whitening gel

• Protective tray case

• Includes Level 1 services

• Free syringe refills at cleaning visits

• Immediate results

• Professionally applied

• Highest strength whitening

• Protective tray case

• Optional $99 retreatments

• Includes Level 2 services

• Free syringe refills at cleaning visits

FREE* $129* $199*

*Program rules apply. See reverse side for details.

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Whitening for Life ProgramOptions For a Brighter, Whiter Smile for Life

Campus Smiles is proud to offer patients our Whitening For Life Programdesigned to help each patient achieve a healthier, brighter, and whiter smile.

Step One:Become a Patient

Step Two:Remain Active

Free Whitening for Life

+ =

Complete your exam, x-rays, and cleaning

appointment

Stay on schedulewith your cleaning

appointments

Receive freewhitening syringe refills

at appointments

The WFL Program is for new and active patients. Program begins after receiving x-rays, exam, and either a routine cleaning or periodontal cleaning. Patient must be decay-free.

Patients must keep their regularly scheduled cleaning, exam, and x-ray appointments (at least twice per year) to maintain program eligibility.

In the event a patient needs to change a cleaning appointment, program rules require that the patient reschedule within four weeks of thepreviously scheduled appointment date to maintain program eligibility (Campus Smiles requires 48 hours advance notice to cancel or change anappointment to avoid a charge).

One whitening gel syringe will be provided free of charge at each completed routine cleaning or periodontal maintenance appointment. Additional syringes can be purchased for $15.00 each.

Lost or destroyed trays will be replaced at a cost of $35.00 for each custom tray and $15 for each generic tray.

Patients who do not successfully meet patient responsibilities will be deactivated from the program, but will be provided the opportunityto re-enroll for a $99.00 reactivation fee.

For any questions or concerns about the Whitening For Life Program, please inquire with a Campus Smiles team member!

By signing below, the patient acknowledges his/her understanding and agreement to the program terms and conditions.

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Program Terms and Conditions

Patient Printed Name Patient Signature Date