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Date of Birth

Patient Phone

Referral Office Phone Number: *

Reason Patient Referred (Check all that apply):

Too Young to Cooperate

Combative

Mental/Physical Challenge

Allergic to Local Anesthetic

Extensive Procedures

Acute Dental Phobia

First Name: *

Last Name

Medicaid / Insurance Number:

Referral Office: *

Signature DDS/MD - Entering an electronic signature makes it a valid signature *

Brief Dental/Medical History

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Patient Information