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CUSTOM BENEFITS SCHEDULE
Please complete this online form or download the blank Benefits Schedule HERE to create your custom benefits schedule. Once submitted an ADN Account Executive will contact you to discuss your desired annual fees and prepare your custom office brochures.
If you would like some assistance completing the form please contact one of our Team Members
Office Name:
Main Address:
Primary Contact:
Phone:

Procedure
Co-Payment
Procedure
Co-Payment
Consultation (excluding specialist)
Initial Exam
Periodic Exam
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