FRD Minor Information Sheet Patient Details

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FRD Minor Information Sheet Primary Insurance Details

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FRD Minor Information Sheet Secondary Insurance Details

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FRD Minor Information Sheet Emergency Contact Information

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FRD Minor Information Sheet Parent or Legal Guardian of Minor Information Sheet

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  •  Yes
  •  No

Approved List of Persons who may bring my child to their appointments and receive information regarding their appointment and/or treatment.

By signing this form I agree to the terms and policies of Flint River Dental. I understand it is my responsibility to notify FRD of any changes or updates in my child(s) medical status, change of address, or change of insurance. I accept responsibility and agree to be obligated to pay the office in accordance with Flint River Dental Financial/Insurance Policy.

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