Pola Whitening System

(727) 391-1963



                                   Whiter. Brighter. You. for life


                                                                Patient Loyalty Program



The Whiter. Brighter. You. for life  Patient Loyalty Program is extended to patients who have proven themselves as individuals who take their oral hygiene and general dental health seriously. We believe it is extremely important to maintain recommended hygiene care appointments and receive necessary dental treatment to maintain a healthy and beautiful smile. In fact, we believe that patients who maintain regular hygiene appointments and receive recommended treatment spend less money on dental care (on average) than those who only see the dentist when they perceive a problem exists. All too often, people who wait until there is a problem have irreversible damage to their gums, teeth, and / or jaw.


We pride ourselves on the smiles that leave our practice. We also pride ourselves on knowing our patients are maintaining the best possible oral health. The Whiter. Brighter. You. for life Patient Loyalty Program was developed as a free gift for those patients that are already taking their dental health seriously, by offering free whitening touch up syringes for life, following a dental care treatment plan and subsequent purchased whitening procedure.


This privilege, while absolutely free, does have some conditions and restrictions. Please review the Terms and Conditions and sign below. You will also receive a copy of our Broken Appointment Policy which is required to be signed by you.


By participating in the Whiter. Brighter. You. for life program, we insist that all Terms and Conditions are followed in order to receive and continue to receive this benefit. Should any of the Terms and Conditions not be met, you will be immediately disqualified from the program until you have met the requirements for re-enrolment.




Terms and Conditions

Eligibility to apply

To be eligible to apply for membership in the program, you must:

a. be at least 18 years of age;

b. complete initial hygiene cleaning, x-rays, doctor’s exam, and re-appoint for two to six month re-care, as prescribed by your dental professional;

c. comply with the minimum required dental care and treatment planned by your dental professional; and

d. purchase an initial tooth whitening treatment including whitening trays (this may be a chair side and / or take home whitening procedure).


Lifetime Maintenance Conditions

Once you have been accepted as a Member, you must:

a.  maintain the minimum ongoing care and treatment prescribed by your dental professional;

b.  maintain continued hygiene care (two to six month hygiene appointments, as prescribed by your dental professional); and

c.  comply with any requirements or directions from your dental professional or this dental office including but not limited to, any policies regarding payments, outstanding accounts or broken appointments.


At any time, we reserve the right to:

a.  make changes to the Terms and Conditions;

b.  terminate, modify or suspend the program;

c.  refuse to supply any whitening syringes or any other product to a Member where we consider such action necessary to prevent misuse, abuse or adverse affect on a Member’s health; and

d.  refuse or terminate membership with any person at our absolute discretion.

We will attempt to notify Members of any changes at their next appointment but will not be liable for any failure to do so.


Member Benefits

Once you have met the Eligibility requirements and subject to the Lifetime Maintenance Conditions, you will receive one touch up tooth whitening syringe at each further hygiene re-care appointment, up to four times annually. Lost or destroyed whitening trays will be replaced at cost to the Member.


I hereby certify that I agree to the Terms and Conditions outlined above.

I also acknowledge receipt of this dental office’s Broken Appointment Policy. I understand that the
Whiter. Brighter. You. for life Patient Loyalty Program is a privilege only bestowed to individuals who meet and maintain all of the Terms and Conditions of the program.





Print Member’s name


__________________________________________________________         _______________

Member’s signature                                                                               Date



Print Dental professional’s name


__________________________________________________________         _______________

Dental professional’s signature                                                              Date


This agreement is between the above signed parties only and is not transferable.

Healthy Smiles

What does your smile say about you? Let us help you radiate confidence with a healthy smile.