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Form 5 Dental Health

Form 5 Dental Health

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MO. DAY YR* A*D*A. Procedure Number Actual Charges Fee H I A J RIGHT LEFT K T S L R Q P O N M DATE DENTAL SERVICES PROVIDED EXAM FLUORIDE PROPHY X-RAYS SEALANTS TREATMENT restoration pulp therapy extraction etc See section below if treatment is not complete OTHER DATE OF NEXT ROUTINE EXAM DENTAL SERVICES NEEDED OTHER Approximate number of visits to complete treatment Dates of scheduled appointment s SUMMARY OF DENTAL SERVICES All planned treatment is complete Treatment was Referred No treatment...
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