Back to plan comparison Membership Enrollment

Enroll your family in the Membership Plan

Add each family member you'd like to enroll, choose Essential or Preferred for each, and submit your request — our front desk will follow up to confirm details and collect payment.

Prefer paper? Download the printable enrollment form

1. Primary Account Holder

This is the person we'll contact to confirm enrollment and payment.

Full name

Date of birth

Home address

Phone

Email (optional)

Are you already a patient here? Yes No

2. Family Members & Plan Selection

Add everyone you'd like to enroll. Prices update automatically.

Total annual membership cost$0

One-time family enrollment fee$50

Total due today$50

3. Payment Method

We'll confirm the exact charge with you before processing anything.

Pay online now (card) Cash Check Card at check-out Card on file

You'll be taken to our secure payment page after submitting, with your total and the right membership items ready to select.

4. Membership Terms

The Membership Plan is not dental insurance and cannot be combined with any dental insurance plan.
Each plan includes 2 cleanings, 2 exams, and routine X-rays per year, plus 1 emergency exam per year, and 15% (Essential) or 20% (Preferred) off restorative treatment and SRP — including fillings, crowns, and bridges — with no annual dollar cap.
Full Mouth X-rays (FMX) and Panoramic X-rays (PAN) are available as a $100 upgrade/add-on beyond the routine annual X-rays included in membership.
Not included and not eligible for the membership discount: CBCT/3D imaging, orthodontic treatment (braces, clear aligners/Invisalign, retainers), and cosmetic procedures (whitening, veneers, cosmetic bonding). These are billed separately at standard rates.
The $50 enrollment fee is a one-time, per-family charge and is non-refundable.
Annual membership fees are non-refundable once paid.
Membership automatically renews annually at the then-current rate unless cancelled in writing at least 30 days before renewal.
Discounts apply only to services performed at Potomac Woods Family Dental Care.

I have read and agree to the membership terms above, and I authorize Potomac Woods Family Dental Care to contact me to complete enrollment and process the payment method selected.

Type your full legal name as your signature

Please fill in your name, phone number, at least one family member, and agree to the terms before submitting.

Your Enrollment Summary

Add a family member to see pricing here.

Membership total$0

Enrollment fee$50

Due today$50