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What Pregnant Women DentalCovers 5 Questions and Answers 6 Grievancesand Appeals 7 General Conditions 8 Termination of Coverage 9 Transportation Assistance Welcome to Pregnant Women Dental This handbook tells you about the dental services covered by your dental program and how to get them Pregnant Women Dental is an agreement
ORLANDO FAMILY & COSMETIC DENTISTRY 3191 Maguire Blvd Suite 251 Orlando, Florida 32803 FINANCIAL POLICY We are pleased that you have selected us as your dental care provider For your knowledge, our Financial Policy is outlined below Promise to Pay Amounts for dental care services provided to you or your family members may be charged to your
S 9)t S 9) Home # XVork # ( E-mail Middle Marital Status State Business Phone Spouse Social Security Number Business Phone Phone State Occupation
Family & Cosmetic Dentistry Confidential Patient Information – Part II A AIDS B Arthritis C Asthma D Cancer E Diabetes F Epilepsy G Glaucoma H Heart Murmur I Heart Problem* J Hepatitis K High Blood Pressure L Jaundice M Kidney Problems N Low Blood Pressure O Nervous Breakdown or Psychiatric Therapy P Rheumatic Fever Q Joint
10 Women: Pregnant? Yes # months No Nursing? Yes No Taking birth control pills? Yes No I understand the above information is necessary to provide me with dental care in a safe and efficient manner I have answered all questions to the best of my knowledge