1. Do You Have An Appointment?

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  2. Password
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  3. You need to make an appointment to continue. Please click here to request an appointment
  1. Your Full Name
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  2. Home Phone
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  3. Cell Phone
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  4. Home Address
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  5. City
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  6. State
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  7. Zip Code
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  8. Your Email Address
    Please provide a valid email address.
  9. Child's Full Name
    You must provide a first name.
  10. Does your child have any Illnesses/Conditions/Diagnoses?
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  11. Please explain:
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  12. Has your child had any recent hospitalizations?
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  13. Please explain:
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  14. Does your child have any current or preexisting allergies?
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  15. Please explain:
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  16. Is your child currently taking any medications?
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  17. Please explain:
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  18. Do you have any other concerns?
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  19. Please explain:
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  21. Child's Full Name
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  22. Does your child have any Illnesses/Conditions/Diagnoses?
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  23. Please explain:
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  24. Has your child had any recent hospitalizations?
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  25. Please explain:
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  26. Does your child have any current or preexisting allergies?
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  27. Please explain:
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  28. Is your child currently taking any medications?
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  29. Please explain:
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  30. Do you have any other concerns?
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  31. Please explain:
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  33. Child's Full Name
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  34. Does your child have any Illnesses/Conditions/Diagnoses?
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  35. Please explain:
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  36. Has your child had any recent hospitalizations?
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  37. Please explain:
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  38. Does your child have any current or preexisting allergies?
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  39. Please explain:
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  40. Is your child currently taking any medications?
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  41. Please explain:
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  42. Do you have any other concerns?
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  43. Please explain:
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  45. Child's Full Name
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  46. Does your child have any Illnesses/Conditions/Diagnoses?
    Please provide an answer.
  47. Please explain:
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  48. Has your child had any recent hospitalizations?
    Please provide an answer.
  49. Please explain:
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  50. Does your child have any current or preexisting allergies?
    Please provide an answer.
  51. Please explain:
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  52. Is your child currently taking any medications?
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  53. Please explain:
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  54. Do you have any other concerns?
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  55. Please explain:
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  57. Child's Full Name
    You must provide a first name.
  58. Does your child have any Illnesses/Conditions/Diagnoses?
    Please provide an answer.
  59. Please explain:
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  60. Has your child had any recent hospitalizations?
    Please provide an answer.
  61. Please explain:
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  62. Does your child have any current or preexisting allergies?
    Please provide an answer.
  63. Please explain:
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  64. Is your child currently taking any medications?
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  65. Please explain:
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  66. Do you have any other concerns?
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  67. Please explain:
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  68. Insurance

  69. Has your child's dental insurance changed?
    Please provide an answer.
  70. Primary

  71. Employer providing insurance
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  72. Subscriber (covered employee)
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  73. Name of Insurance carrier (company)
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  74. Insurance ID number or badge number
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  75. Secondary (if applicable)

  76. Subscriber (covered employee)
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  77. Employer providing insurance
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  78. Name of Insurance carrier (company)
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  79. Insurance ID number or badge number
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  80. Topical fluoride applications are routinely done at every six-month preventative visit.

    The American Academy of Pediatric Dentistry guidelines recommends the application of fluoride and dental examination every six-months; however, some insurance plans may only cover these services once a year. Please refer to your insurance handbook for coverage limitations.

  81. You must agree to these terms to submit this form.
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