All payments require a signed Financial Agreement.

Please submit the Financial Agreement at the time of initial deposit or payment. It may be:

  • Submitted in person at your dental office
  • Emailed to
  • Faxed to (404) 592-5505
  • Uploaded by clicking the upload link below

Financial Agreement Form
English.pdf (1 download)  
Spanish.pdf (1 download)

Upload Financial Agreement fileuploadicon

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If services aren’t rendered on the scheduled day, a refund will be initiated within 10 business days of the missed procedure day.  Refund processing time is determined by your payment processor or credit card provider.

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