A dental membership plan template should define four building blocks: a preventive bundle for one monthly or annual fee (typically two cleanings, two exams, and routine X-rays a year), a discount on other treatment, add-ons, and renewal terms and rewards. It also needs a written patient agreement that states plainly that the plan is not insurance, plus a check against your state's rules. Clerri built the free template below around that compliance check.
What a dental membership plan should include
A dental membership plan should include four building blocks: a preventive bundle, a discount on other treatment, add-ons, and renewal terms and rewards. For plans that span several locations, see our guide for DSOs and growing practices.
The American Dental Association advises being "very specific" about which procedures a plan includes and how often, since a clear written statement of what is and is not included "will minimize the chance of any dispute down the road" (ADA, 2022).
1. Preventive bundle
The baseline is two cleanings, two exams, and routine X-rays per plan year, each written with its frequency ("2 periodic exams per plan year"). Across the Clerri platform, patients pay about $30 per month or $360 per year on average for preventive care that includes cleanings, exams, X-rays, fluoride, and an emergency visit (Clerri patient FAQs).
2. Treatment discount
Members get a percentage off your usual fees for anything the bundle does not include. On average across the Clerri platform, members save 10% to 25% on other procedures. List the procedures the discount applies to (for example, fillings, crowns, root canals, and extractions) and say whether orthodontics, implants, cosmetic work, and outside lab fees are excluded or discounted at a lower rate.
3. Add-ons
The common add-ons are fluoride, periodontal maintenance, and an emergency (limited) exam. Include one in a tier when most patients in that tier will use it, and otherwise offer it at the member discount.
4. Renewal terms and rewards
A renewal (or rollover) reward, such as letting an unused included service or a loyalty credit carry into the next plan year, gives members a reason to stay into year two. Put the renewal terms, and how any reward is earned and expires, in the agreement. This guide to renewal rates covers the operational side.
Dental membership plan tier templates
Adult, child, senior, and perio maintenance tiers cover most practices. Copy each template into your plan documents and fill in the blanks.
Pricing worksheet for any tier
To price a tier, total your own fees for the included services, set the annual fee below that total, then set the treatment discount.
- List each included service, your usual fee, and how many times per plan year it is included.
- Multiply and add the lines to get the annual value of the bundle at your fees.
- Set the annual fee below that total so joining is a clear saving, but above what the bundle costs you to deliver at full use (chair time, supplies, and a share of overhead).
- Set the monthly fee: the annual fee divided by 12, or slightly more if you want to reward paying up front.
- Set the discount on other treatment. On average across the Clerri platform, members save 10% to 25% on other procedures.
- Set family pricing. Most plans on the Clerri platform offer a 5% to 10% discount for adding family members.
The ADA adds one test: whether revenue lost by discounting fees for existing cash patients is offset by new patients and by treatment they had delayed (ADA, 2022).
Worked example (example fees only, not benchmarks):
- 2 periodic exams: 2 x $60 = $120
- 2 adult cleanings: 2 x $110 = $220
- 1 set of bitewing X-rays: 1 x $70 = $70
- 1 emergency (limited) exam: 1 x $90 = $90
- Annual value at these example fees: $500
- Example annual fee: $399, so a member who uses the whole bundle saves $101
- Example monthly fee: $35 ($420 over twelve months)
Adult tier template
- Who it's for: patients age ___ and older who do not need periodontal maintenance
- Included each plan year: 2 periodic exams, 2 adult cleanings, bitewing X-rays at the frequency your clinical protocol sets, 1 emergency exam
- Optional add-on: fluoride
- Discount on other treatment: ___%
- Not included: ___ (for example, outside lab fees, specialist referrals, orthodontics)
- Price: $___ per year or $___ per month
Child tier template
- Who it's for: patients through age ___
- Included each plan year: 2 exams, 2 child cleanings, fluoride at each cleaning, X-rays as clinically indicated, 1 emergency exam
- Discount on other treatment: ___%, noting whether it applies to sealants
- Not included: ___
- Price: $___ per year or $___ per month
Senior tier template
- Who it's for: patients age ___ and older
- Included each plan year: 2 periodic exams, 2 adult cleanings, X-rays at the frequency your clinical protocol sets, 1 emergency exam
- Optional add-on: fluoride, if your clinical protocol recommends it
- Discount on other treatment: ___%, noting whether it applies to dentures, partials, and relines
- Not included: ___
- Price: $___ per year or $___ per month
Perio maintenance tier template
- Who it's for: patients who have finished active periodontal therapy and are on a maintenance schedule
- Included each plan year: perio maintenance visits at your protocol interval in place of standard cleanings (for example, 4 visits for a three-month interval), 2 exams, X-rays per protocol, 1 emergency exam
- Discount on other treatment: ___%
- Tier change rule: when a patient moves between the adult and perio tiers, and how the fee changes
- Price: $___ per year or $___ per month
Patient agreement checklist
The patient agreement should state exactly what the member pays, what they get, how the plan renews and ends, and that the plan is not insurance. The ADA recommends a signed agreement that describes the terms "fully, accurately, and unambiguously," and its sample clauses shaped this list (ADA, 2022).
- Fee and billing: amount, monthly or annual, billing date, written consent to recurring card or bank charges, and what happens if a payment fails
- What's included: each service, how often per plan year, and when membership starts, including any waiting period
- What's excluded: services, lab fees, and referrals the plan does not include
- Discount terms: the percentage and which procedures it applies to
- Plan changes: how much notice members get before a fee or included-service change
- Auto-renewal: whether the plan renews automatically and how you notify the member first
- Cancellation and refunds: how the member or the practice can end a membership (for example, after repeated failed payments), notice required, and what happens to unused services
- Transfers: membership is personal, not transferable, and has no cash value
- Missed appointments: whether a missed visit counts against the bundle
- Eligibility and family pricing: who can join and how family discounts apply
- Not insurance: a plain statement that the membership plan is not insurance
- Practice contact info: who members contact with plan questions
- State-required disclosures: any language your state requires
- Enrollment form: name, date of birth, contact details, tier, start date, billing choice, payment consent, signature, and date
State rules vary, so treat this checklist as a starting point, not legal advice, and have the final agreement reviewed by an attorney familiar with your state. The ADA holds advertising to the same standard as the agreement. Describe what's included and what it costs, and avoid comparisons to insurance.
State compliance considerations
Whether an in-house plan falls under state discount plan rules depends on your state and how the plan is built. 36 states license Discount Medical Plan Organizations (DMPOs), and California adds Knox-Keene on top (Clerri compliance and security).
Three points trip practices up:
- The name does not decide the rules. In most states that regulate discount plans, a fee-for-discount plan is treated the same way whatever it is called, according to Clerri's dental membership plan compliance guide.
- Exceptions vary. Some states exempt discounts a provider gives its own patients, but per the same guide, some exceptions apply only to discounts offered without a fee. The ADA also counted 20 states (as of June 2022) whose direct primary care agreement laws include dentists; those laws generally exempt qualifying agreements from insurance oversight but carry their own contracting and patient-notice rules (ADA, 2022).
- Network contracts matter. The ADA notes that under a carrier contract with a "most favored nation" clause, a lower plan fee could reduce what that payer reimburses you (ADA, 2022).
For state-level detail, read the state-by-state breakdown of membership plan compliance. Clerri holds DMPO licenses in all 36 states that require them, is Knox-Keene compliant in California, and builds every plan to applicable laws in all 50 states.
How to create an in-house dental membership plan
To create an in-house dental membership plan, build your tiers from the template above, price them from your fee schedule, get the agreement reviewed, then train your team and launch to existing patients.
- Set goals. Decide who the plan is for (often patients who pay for care themselves) and what it should achieve.
- Build the tiers. Copy the templates and choose which add-ons each tier includes.
- Price each tier. Run the worksheet with your own fees.
- Write and review the agreement. Work through the checklist, then have it reviewed for your state.
- Set up billing and tracking. Run the plan from a spreadsheet, your practice management software, or a membership platform such as Clerri that handles billing, renewals, and member status. Use a PCI DSS compliant processor for card payments, and record membership status where your team schedules patients.
- Train and launch. Give the front desk a one-sentence explanation of the plan, then market it through recall messages, signage, and your website.
- Review and adjust. After six to twelve months, check enrollment, renewals, and how often members use their included visits, then adjust price or inclusions with the notice your agreement promises.
For the full launch path, including plan design with a specialist, see how to start a dental membership plan with Clerri. Setup is free, and most practices are live in about two weeks.
Download the worksheet
Prefer to work on paper? Download the free worksheet (PDF). It has the pricing worksheet, all four tier templates, the patient agreement checklist, and the state compliance notes in a printable format, with no form to fill out first.
Dental membership plan template FAQs
What is a dental membership plan template?
It is a fill-in framework for an in-house plan that sets out the preventive bundle, the discount on other treatment, add-ons, renewal terms and rewards, and the patient agreement. The Clerri template on this page includes four tier templates, a pricing worksheet, and an agreement checklist, free to copy with no form.
What should a dental membership plan include?
A dental membership plan should include four building blocks: a preventive bundle (typically two cleanings, two exams, and routine X-rays a year), a discount on other treatment, add-ons, and renewal terms and rewards. On average across the Clerri platform, members save 10% to 25% on other procedures. The written agreement should also set out billing and cancellation terms and state clearly that the plan is not insurance.
How do I create an in-house dental membership plan?
Design the bundle and tiers, price them from your own fees, and have the patient agreement reviewed for your state. Then set up billing, train your team, launch, and adjust after six to twelve months.
How many tiers should a dental membership plan have?
Adult, child, senior, and perio maintenance tiers cover most practices. Start with the tiers your patient mix calls for; many practices launch with adult and child and add the others as demand shows up.
Does an in-house dental membership plan need a compliance review?
Yes. The ADA calls it imperative to have the plan and accompanying agreement reviewed by a competent attorney. 36 states license Discount Medical Plan Organizations and California adds Knox-Keene requirements, and whether those rules apply depends on the plan's structure and state. Some practices also work with a partner that holds the required licenses.
