Direct Mobile Dentistry - Consent Form

I authorize DMD, Direct Mobile Dentistry, to provide routine preventative and diagnostic services such as examination, cleaning and scaling of teeth.  I understand this fee to be $140.00.  For the examination, cleaning and adjustment of dentures, I understand the fee to be $75.00. Further treatment will not be started without the patient, family or caregiver giving further consent. 

     
   
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Cohen Care Center for Dental Health | 2480 Windy Hill Rd SE – Suite 202 – Marietta GA 30067 | Phone 770.272.0222 | Fax 770.272.0204
Payment Methods Visa Mastercard Checks Cash | Most Dental Insurances Accepted