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Pediatric Dental Career Opportunities in Cedar Rapids, Coralville, Muscatine, & Davenport, IA
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Dentists
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Dental Cleanings
Dental Crowns
Dental Fillings
Dental Sealants
Dental X-Rays
Dentistry with Nitrous Oxide
Emergency Care
Fluoride Treatments
Oral Health Exams
Pulpotomies/Root Canals on primary teeth
Sports Mouthguards
Tooth Extractions
Parents
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About Us
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Contact Us
Pediatric Dental Career Opportunities in Cedar Rapids, Coralville, Muscatine, & Davenport, IA
Personal Intake Form
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Please list below any individual that can bring your child(ren) to their appointments. By listing their name you are also consenting to give this individual(s) permission to receive information, the right to sign the medical history and consent to routine dental treatment.
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Please read each statement and signify approval by checking the box beside it:
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I am certifying that the information listed is complete and accurate.
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I am the legal guardian of the children identified above.
I read and understand the Photo Release Form
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Photo Release Form
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I have read and understand the
Privacy Act Document
.
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I will be responsible for any fees not covered by my insurance company and have read and understand
Dentist For Kidz Insurance and Office Polices
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Entering your name and date below serves as your electronic signature and confirms that the information submitted in this form is valid and accurate:
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