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I'm filler tells fluid filer 5K.SSE HH!HSBJSSLwww.forsythfamilydental. Com ID; First Name: Patient Is: Preferred Name:Policy HolderMiddle Initial:Last Name:responsible PartyResponsible Party (if someone
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It is a dental clinic located in Forsyth County.
All licensed dentists practicing at the clinic must file.
You can fill out the form online or in person at the clinic.
The purpose is to report dental services provided to patients.
Information such as patient demographics, services rendered, and billing codes.
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