East Atlanta Family Dental



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East Atlanta

Family Dental

440 Flat Shoals Ave SE Atlanta, Georgia 30316

SMDental P.C.

Dr. Shervin Meshkian DDS FICOI

T: (404) 688-2223

F: (404) 688-6602

Dental Practice Policy

Dear Patients:

Please read each paragraph and sign at the bottom

Welcome to our dental office. We appreciate the opportunity to assist with your dental needs and Concerns. Our goal is to provide the best dental care available efficiently and professionally.

Together we can accomplish this goal. We take pride in providing excellent patient care, understanding of treatments, and educating our patients. However, like any business we have office policies that we must adhere to so that we can operate in a manner that will benefit our relationship. This office policy serves as an agreement between East Atlanta Family Dental, as a creditor, and the patient/debtor signed below.

We must have 48 hr notice should you be unable to keep your appointment. We make every effort to confirm your appointment; however, it is your responsibility to keep your designated appointment time reserved just for you. Failure to give 48 hr notice will result in $35.00 per scheduled hour of treatment broken appointment charge. We reserved time exclusively for you and must know of any changes ahead of time. INITIALS______________.

All co-pays are due at the time of treatment. As a courtesy, we will be happy to file your primary insurance claim. Please understand that treatment is NOT dependent on payment from your insurance company. Fees quoted are an estimate only based on information provided by your insurance policy. Insurance payments are not a guarantee of payment. Insurance claims that are not paid after 45 days become your responsibility in full. We will be happy to provide you with claims and information submitted to insurance on your behalf.

You are responsible for filing to any secondary insurance you may have. As a courtesy we will assist you with the process.

As a creditor you give us permission to check your credit and employment status for the purpose of financial planning, credit extension, and debt collecting. Any account that becomes 30 days past due will incur a 22% APR finance charge based on the unpaid balance. In the event that your account remains past due we will send your account to our collection agency. Your account will then be charged a 35% collection fee in addition to your unpaid balance. If we have to refer collection of your balance to our lawyer, you will pay all lawyer’s fees which incur plus court costs.

Return checks, stop payments, and credit card charge backs incur a $35.00 fee or 7% of the face value, whichever is greater, and an amount equal to charges from our bank.

All products sold in our office are non-returnable.

We try very hard to adhere to a schedule. In order to provide quality care in a timely manner to patients in need, our office will attempt twice to confirm your appointment via phone call or email. It is patient/guardian responsibility to secure their schedule appointment by confirming it 48-24hrs prior. If we do not receive a confirmation we will assume the spot cannot be kept and it will be given to another patient in need. Sometimes emergencies occur that will make us run behind, please be patient with us as it could be you with that emergency. We do respect your time and make every effort to stay on schedule. We thank you for choosing our dental team and look forward to a long lasting relationship with you and your family. Dentistry and surgery are not exact sciences and no guarantees are made concerning the results of any procedures or operations.

______________________________ (Patient Signature / Guardian if under 18) ________________ (Date)

E as tAtl Family D en tal.c om

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