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  • Atlanta Place Dentistry

    YOURTULSADENTIST.COM
  • BEFORE YOU BEGIN

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  • WHAT WILL YOU NEED IN THIS PROCESS?

    You will be asked to provide 1) a photo of your insurance cards and 2) a valid form of identification in this process. Once you have those ready, click next.
  • General Information

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    • CLICK HERE TO ADD ADDITIONAL FAMILY MEMBERS TO YOUR FILE 
  • Billing Information

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  • Financial Policies:

    If payment for the entire new balance within 25 days of the monthly billing date, or settlement of pending insurance claims, a service charge will be added to the account for the current monthly billing period. The service charge will be a periodic rate of 1.5% per month (or a minimum charge of $3.00 for a balance under $200.00) which is an annual percentage rate of 18% applied to the last month’s balance. In the case of default of payment, I promise to pay any legal interest on the balance due, together with any collection costs and reasonable attorney fees incurred to effect collection of this account or future outstanding accounts.
  • Insurance Information

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  • PERMISSION TO SUBMIT INSURANCE CLAIMS:

    By providing the information above, I hereby authorize payment directly to the Dental Office of the group insurance benefits otherwise payable to me. I hereby authorize the Dental Office to administer such medications and perform such diagnostic, photographic and therapeutic procedures as may be necessary for proper dental care. The information on this page and the dental/medical histories are correct to the best of my knowledge. I grant the right to the dentist to release my dental/medical histories and other information about my dental treatment to third party payors and/or other health professionals.
  • We Love Non-Insurance Patients

    OUR MEMBERSHIP COULD BE PERFECT FOR YOU!
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  • Medical History

    • CLICK HERE IF YOU WILL NEED PRE MEDICATION BEFORE YOUR APPOINTMENT 
    • If you are in need of premedication for your first visit, please contact your primary care physician to fulfill this request. Once you are a patient of record, we will be able to fulfill this request in the future.

  • Medical History, Part 2

  • PLEASE ADVISE US IN THE FUTURE OF ANY CHANGE IN YOUR MEDICAL HISTORY OR ANY MEDICATIONS YOU MAY BE TAKING.

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  • REQUEST OF DENTAL RECORDS

    • (Optional) Click Here to Begin the Dental Record Transfer Process 
    • Please Contact Your Previous Dentist:

      Most clinics require you to make the initial request to transfer your dental records. Please contact your previous clinic and request x-rays and previous clinical notes to be sent to info@yourtulsadentist.com.
    • Dear Insurance Patients:

      Please be aware that your dental insurance will MOST LIKELY NOT INFORM a new clinic of your dental insurance frequencies and duplicate services may not be covered. Please contact your insurance company to ensure duplicate services will be covered.
  • Terms and Policies, Page 1 of 3

  • Terms and Policies, Page 2 of 3

  • Terms and Policies, Page 3 of 3

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