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THIBAUT REGIONAL WOMEN CLINICAgreement to Accept Responsibility (No Insurance Card) I have presented for services without a current insurance card. I understand that it is my responsibility to provide
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Emergency dental services without insurance coverage.
Individuals seeking emergency dental services without insurance coverage.
You can fill out the form online or visit a dental clinic in person.
To provide emergency dental care for individuals without insurance coverage.
Personal details, dental issue, and payment method.
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