Smiles 4 Tampa Bay - Consultation Form:
Please complete the following form, and an agent will contact you with the details about our program:
Immediate Need (Check All That Apply):
Do you currently wear dentures or partials?
If yes, how long have you been wearing the current set? If no, how long have you been without?
Are you experiencing any discomfort or pain?
Is there anything else you would like us to know?
How did you hear about us?
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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This form was created inside of National Association For Medical & Dental.