Appointment Requests

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Patient appointments for SmileFaith Veterans Dental Clinic

Email *

Today's Date: *

YYYY

First Name: *

Last Name: *

Phone Number: *

Immediate Need: *

Are you experiencing any discomfort or pain? *

Yes

IMPORTANT NOTICE: This form is confidential and HIPAA compliant, it may be legally privileged. It is for the intended recipient only. Access, disclosure, copying, distribution, or reliance on any of it by else is prohibited and may be a criminal offense. If you are not the intended addressee please delete and do not use or distribute this message, and please notify the sender by return email. Personal views and opinions expressed in this communication are those of the originator and may not necessarily reflect those of the originator's associated company. *

I understand and agree that all information on this application is true, and correct to the best of my knowledge, and I understand that if I provide false information it is a violation of this agreement.

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