ERIE COUNTY DEPARTMENT OF JOB AND FAMILY SERVICES by s90P2am8

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									       ERIE COUNTY DEPARTMENT OF JOB AND FAMILY SERVICES
                                                       221 West Parish Street
                                                       Sandusky, Ohio 44870
                                             http://www.erie-county-ohio.net/jfs/welcome.htm


Director, Judith K. Englehart                                                                         Phone: (419) 626-6781
Interim Assistant Director, Aaron A. Voltz                                                            Fax: (419) 626-5854


                             DENTIST EXAMINATION VERIFICATION

CHILD’S NAME:__________________________________________________________________________

DATE OF BIRTH:__________________________________________________________________________

DATE OF EXAMINATION:__________________________________________________________________

DENTIST’S NAME:________________________________________________________________________

ADDRESS:________________________________________________________________________________

PHONE NUMBER:_________________________________________________________________________

PLEASE LIST THE SERVICES PERFORMED AT THE EXAMINATION:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

DIAGNOSIS, TREATMENT AND RECOMMENDATIONS:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

NEXT APPOINTMENT:_____________________________________________________________________

DENTIST’S SIGNATURE:___________________________________________________________________

DATE:____________________________________________________________________________________



*Please have form completed for all dental services provided to child. Return with monthly reports.

								
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