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NDate of Birth Form
Cleaning Fluoride varnish Dental sealants Counseling/Anticipatory Guidance Referral to Specialty Care Restorative/Emergency Care Fillings Crowns Emergency care Other Please specify specialist Future Oral Health Care Services All treatment completed More appointments needed for treatment If yes Approximate number of appointments needed Next recall date / Next appointment Date month/year Time Additional Information for Parents Head Start Staff and Medical Providers Oral Health Provider s Contact...
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