POPPY KIDS PEDIATRIC DENTISTRY
DENTAL MEMBERSHIP PLAN AGREEMENT
Effective Date: January 1, 2026

Poppy Kids Pediatric Dentistry is a pediatric dental practice which delivers dental services at 450 Ignacio Blvd, Novato, CA, 94949. In exchange for certain fees, the Practice agrees to provide the Patient and You with the Services described in this Agreement, on the terms and conditions contained in this Agreement.

DEFINITIONS
1. Parties to this Agreement.
a. Patient- In this Agreement, “Patient” means the person for whom the Dentist shall provide care, and whose parent, guardian, or other responsible party has entered into this Agreement through online enrollment or is listed on the document attached as Appendix B, which is made a part of this Agreement.
b. “We” and “Practice” mean Poppy Kids Pediatric Dentistry.
c. “You” and “Your” mean and refer to the parent, legal guardian, or other responsible party who executes this Agreement and agrees to pay all fees and costs for the Services.
d. “Party” means either You or Poppy Kids Pediatric Dentistry. “Parties” means both You and Poppy Kids Pediatric Dentistry.
2. Services- In this Agreement, “Service” or “Services” mean the services offered to Patient by Practice under this Agreement. These Services are listed in Appendix A, which is attached to and a part of this Agreement.
3. NOTICE: THIS AGREEMENT DOES NOT CONSTITUTE DENTAL INSURANCE, IS NOT A DENTAL PLAN THAT PROVIDES DENTAL INSURANCE COVERAGE, AND IS NOT INTENDED TO REPLACE DENTAL INSURANCE. THIS MEMBERSHIP PLAN WILL COVER ONLY DENTAL SERVICES AS DESIGNATED IN THIS AGREEMENT.
4. Term. This Agreement will last for a period of 12 months (1 year) (the “Term”), starting on the date this agreement is accepted through online enrollment and expiring at the end of the 12 months.
5. Renewal. This Agreement will not automatically renew. To renew this Agreement and the Services plan, You must re-enroll via our website at:
www.poppykidsdental.com/membership
once the previous membership period has expired or terminated.
6. Termination. You always have the right to cancel this Agreement before the end of the Term. Either party can cancel this Agreement at any time. If canceled, there is a 12-month waiting period before renewal is permitted.
7. Services, Payments, and Refunds. Amount and Methods. In exchange for the Services described in Appendix A, you agree to pay Poppy Kids Pediatric Dentistry a yearly fee in the amount that appears in Appendix C, which is attached to and part of this Agreement. The Services included in Your membership plan are eligible to be used over the course of a maximum of two preventive dental care visits per year. Each visit may include: One dental examination (comprehensive or periodic), one preventive dental cleaning, one fluoride treatment, and routine diagnostic X-rays associated with preventive care, including bitewing, periapical, and occlusal radiographs. For all other dental services, You and the Patient shall receive a discount off the usual and customary rates and fees of fifteen percent (15%). If You or the Patient decline a specific service (as an example only, fluoride treatment), the yearly fee shall not be reduced or adjusted, but shall remain as described in Appendix C. If Your and Patient’s membership plan expires (12 months after the plan membership begins), then any unused benefits, treatments, or payment credits under the plan shall be forfeited and shall not roll over into any subsequent 12 months period of any subsequent membership plan period.
If this Agreement is canceled by either Party before the expiration of the Term, We will review and settle your account as follows: We will refund to You the unused portion of your fees on a per diem basis; or if the value of the Services that Patient received over the term of the Agreement exceeds the amount You paid in membership fees, then You shall be obligated to pay the Practice an amount equal to the difference between the value of the Services received and the amount You paid in membership fees over the term of this Agreement. The Parties agree that the value of the Services is equal to the Practice’s usual and customary fee-for-service charges outside of this Agreement.
8. Non-Participation in Insurance. Your acceptance of this Agreement through online enrollment acknowledges that You understand that neither the Practice nor its Dentists participate in any health insurance or HMO/DHMO plans or panels and cannot accept Medicare. We make no representations that any Services or any fees that You pay under this Agreement are covered by your health insurance or other third-party payment plans. This membership plan CANNOT be combined with any dental insurance.
9. This is not Dental Insurance. Your acceptance of this Agreement through online enrollment acknowledges your understanding that this Agreement is not an insurance plan or a substitute for dental insurance. You understand that this Agreement does not replace any existing or future dental insurance that You or Patient may carry or have. You cannot use this Membership plan if you also use a Dental Insurance Plan. NOTE, do not enroll in or enter into this Agreement if you intend to use any Dental Insurance Plan.
10. Communications. You, and You for the Patient, acknowledge that although Poppy Kids Pediatric Dentistry shall comply with HIPAA privacy requirements, communications with the dentist using email, fax, video chat, cell phone, texting, and other forms of electronic communication can never be absolutely guaranteed to be secure or confidential methods of communication. As such, You, and You for the Patient, expressly waive the Dentist’s obligation to guarantee confidentiality with respect to the above means of communication. You, and You for the Patient, further acknowledge that all such communications may become part of the Patient’s dental record.
By providing an email address and phone number on the attached Appendix B and/or during online enrollment, You, and You for the Patient, authorize Poppy Kids Pediatric Dentistry and its Dentists to communicate with You and the Patient by email regarding the Patient’s protected health information (“PHI”). You, for yourself and for the Patient, further acknowledge that:
● Email is not necessarily a secure medium for sending/receiving PHI and there is always a possibility that a third party may gain access:
● Although the Dentist will make all reasonable efforts to keep email communications confidential and secure, neither the Practice nor the dentist can assure or guarantee the absolute confidentiality of email communications.
11. Severability. If any part of this Agreement is considered legally invalid or unenforceable by a court of competent jurisdiction, that part will be amended to the extent necessary to reasonably reflect the Parties’ intent and be enforceable, and the remainder of the contract will stay in force as originally written.
12. Reimbursement for Services Rendered. If any part of this Agreement is considered invalid for any reason, and the practice is required to refund fees paid by You, You agree to pay the Practice an amount equal to the fair market value of the dental services that Patient received during the time period for which the refunded fees applied.
13. No Amendment. No amendment of this Agreement shall be binding on a Party unless it is in writing and agreed to by all the Parties.
14. Assignment. This Agreement, and any rights You may have under it, may not be assigned or transferred by You.
15. Legal Significance. You acknowledge that this Agreement is a legal document and gives the parties certain rights and responsibilities. You also acknowledge that You have had a reasonable time to seek legal advice regarding this Agreement and You have either knowingly chosen not to do so or have consulted with an attorney about this Agreement. You are satisfied with and agree to the terms of this Agreement.
16. Entire Agreement. This Agreement contains the entire agreement between the parties and replaces any earlier understandings and agreements, whether those were written or oral.
17. No Waiver. In order to allow for flexibility of certain terms of this Agreement, You agree that Practice may choose to allow a delay in or not enforce some or all Your obligations under this Agreement (for example, notice periods or payment obligations). You agree that by doing so, Practice will not waive Your duties or responsibilities under this Agreement, and Practice will still have the right to enforce such terms again at any time.
18. Jurisdiction. This Agreement is governed by and construed under the laws of the State of California. Any litigation arising out of disputes involving the Parties and their duties and obligations under this Agreement shall be litigated in the courts of Marin County, California, and the Parties agree to such venue and jurisdiction.
19. Service of Notice. All written notices to You are deemed served if sent to the address or email address that You provide during online enrollment or to the Practice, and those Notices may be sent to You by first class U.S. Mail or email.

APPENDIX A: SERVICES
1. Dental Services. Dental Services under this Agreement are those dental services that the Dentist is permitted to perform under the laws and regulations of the State of California, are consistent with the Dentist’s training and experience, are usual and customary for a dentist to provide, and include the following:

Benefits:
2 Dental Exams (Comprehensive or periodic) and 2 Cleanings
2 Fluoride treatments
Routine Radiographs as indicated at Recare appointments. Includes periapicals, bitewing, occlusals.

Services included in membership plan are eligible to be used over the course of a maximum of two preventive dental care visits per year. Each visit may include the above-described Services and treatment. For all other dental services, You and the Patient shall receive a discount of 15% off the usual and customary rates and fees charged by of Poppy Kids Pediatric Dentistry. Payment for Services must be paid in full at time of treatment and according to Poppy Kids Pediatric Dentistry’ payment requirements. Extended payment plans, including third party financing, are not applicable to this program. If You are making installment payments, and Your payment method is declined, then You will be ineligible to renew the membership for Patient on any installment plan and thereafter You must pay in full at time payment is declined or on plan renewal. If Your and Patient’s membership plan expires (12 months after the plan membership begins), then any unused benefits, treatments, or payment credits under the plan shall be forfeited and shall not roll over into any subsequent 12 months period of any subsequent membership plan period.

Payment Plan Terms
Poppy Kids Pediatric Dentistry (the business)
Effective Date: January 1, 2026
By clicking the submit button on the payment page and authorizing the charges on your card for today or at a future date, You understand you are entering into a legal and binding contract with Poppy Kids Pediatric Dentistry, and You will pay the total amount shown on the payment page, to be paid on each date as shown in the payment schedule accessible via the payment page, a copy of which will also be emailed to You for reference.
You acknowledge and agree that the credit card(s), debit card(s) or other payment method(s) that You are using to make this purchase are and will be active, valid and have sufficient funds available during the entire term of the payment schedule.
If, for any reason, any of your payments are declined or denied by your financial institution or by You, then You agree to immediately provide an alternative, valid payment method. You understand that You may be charged a late fee(s) if a payment is missed on any of the agreed-upon payment dates for any reasons whatsoever that are not caused by Poppy Kids Pediatric Dentistry.
You understand that You are legally bound to these terms and required by law to make all payments on the agreed-upon payment dates, or via an early payment.
Poppy Kids Pediatric Dentistry reserves the right to report any delinquent payments to credit agencies and collections agencies.

Electronic Acceptance: I certify that I have read and understand the Dental Membership Plan Agreement and its Appendices, and I agree to be bound by their terms and conditions. The information I provided on this form and any other information I provide to Poppy Kids Pediatric Dentistry is accurate. I acknowledge that my questions about anything in this Agreement and regarding the Services have been fully answered to my satisfaction. I will not hold my dentist or any other member of their staff liable or responsible for any actions they take or do not take because of errors or omissions that I may have made in the completion of this form or inaccurate information provided by me or Patient. I agree to fully hold harmless Poppy Kids Pediatric Dentistry and its dentists and any staff from any errors or omissions caused by the undersigned or by the Patient providing inaccurate information.