Payment/Consent Form

Consent Form and Payment Options

Consent forms can be downlowed for completion. Please print, sign and email all consent forms to info@seniorsmilesga.com ; or mail to the

Senior Smiles office BEFORE the scheduled dental appointment.

You may also leave the consent form with the Care Director at your community.

Mailing Address: Senior Smiles 4002 Hwy 78 Suite 530-128

Snellville, GA 30039

Unfortunately, we will NOT be able to see anyone without a completed consent form including the responsible party's signature.

THANK YOU!

SENIOR SMILES 2023 CONSENT FORM (pdf)

Download

Payments should be made before or on the day of appointment

We accept checks, all major credit cards and ZELLE.

Call or ZELLE (678) 778-0587

**For ZELLE, please include client name and invoice #.

We make it easy to pay by phone or in person.

Please send your check to:

Senior Smiles

4002 Hwy 78

Suite 530-128

Snellville, GA 30039

We will email you an itemized statement and oral assessment after each appointment.

In accordance with the Privacy Regulations created by the Health Insurance Portability and Accountability Act of 1996 (HIPAA), Senior Smiles uses an encrypted email service on our secure website.

Dental Hygiene Care for Elders We come to your community!

Consent Form and Payment Options

Payments should be made before or on the day of appointment

We accept checks, all major credit cards and ZELLE.

We will email you an itemized statement and oral assessment after each appointment.