Patients Name:

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Address: (Full Address Including Zip Code)

New or Returning Patient?—Please choose an option—New PatientReturning Patient - Looking to Schedule CleaningReturning Patient - With a ProblemReschedule Appointment

Is Your Child in Pain?—Please choose an option—YesNo

Pain Level:—Please choose an option—012345678910

I'm looking for an appointment in...—Please choose an option—Fort MyersNaplesNo Preference

I'm looking for an appointment on...MondaysTuesdaysWednesdaysThursdaysFridaysAny Day

I'm looking for an appointment in the...—Please choose an option—MorningAfternoonAnytime

Do you have dental insurance?—Please choose an option—YesNo

Insurance Type?—Please choose an option—Self PayAllegiance PPOCigna HMO (7 & under)Cigna PPODelta DentalBlue Cross & Blue Shield PPO – (FEP & FCL Blue Dental)Guardian PPOHumana PPOMetlife PPOAetna (PPO)Sunlife (PPO)United Concordia (PPO)United Health Care (PPO)Medicaid /Florida Healthy KidsDentaQuestMCNALibertyOther

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Holders Date of Birth:

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When was your child last seen by a dentist?

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