LOCAL INTAKE ASSESSMENT - Section 9 - Dental

Local Full Name

First Name

Last Name

Current Dentist Name

First Name

Last Name

Current Dentist Phone Number

(###)

###

####

Dentist's Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of last visit

YYYY

Reason

Dental up to date?

Yes

Does local need to be reassigned to a new dentist through the wellness collective?

Yes

Does the local have any dental devices?

Does the local maintain their dental hygiene independently?

Dental work needed?

Comments

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SOUTHWIND FIELDS IS A NONPROFIT 501(C)3 ORGANIZATION

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