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Patient Registration and Medical History Family Legacy Dental 845 North 100 West Suite 100 Orem, Utah 84057 Office... 8012275080 Fax.......... 8012277887Patient Information (CONFIDENTIAL)Date Name
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To fill out family legacy dental, follow these steps:
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Start by gathering all the necessary information such as personal details, contact information, and insurance information.
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Begin filling out the patient information section by including the names, dates of birth, and relationships of all family members who will be covered under the plan.
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Provide the requested insurance details, including policy numbers and any necessary documentation.
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Indicate the desired coverage level and any additional dental services required.
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Review the completed form for accuracy and completeness.
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Submit the filled-out form through the designated channel, such as online submission or mailing it to the appropriate address.
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Keep a copy of the form for your records and await further communication regarding your family's dental coverage.

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Family Legacy Dental is a program that provides dental services for families.
All eligible family members are required to file Family Legacy Dental.
Family Legacy Dental can be filled out online or by submitting a paper application.
The purpose of Family Legacy Dental is to ensure that families have access to dental care.
Family Legacy Dental requires information such as family members' names, ages, and dental insurance information.
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