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MEDICALDENTALENROLLMENT FORMOPTOMETRYThank you for choosing HEALS, Inc. as the healthcare provider for your childless complete all pages in this packet to register your child with HEALS. If not completed
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Obtain the heals-medical-dental-optometry-enrollment-form from the appropriate provider or office.
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Fill in your personal information accurately, including your full name, contact information, and date of birth.
03
Provide details about your medical, dental, and optometry history, as well as any current health conditions or concerns.
04
Indicate your preferred primary care provider, dentist, and optometrist if applicable.
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Sign and date the form to certify that all information provided is true and complete.

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Individuals who are seeking medical, dental, and optometry services through a HEALS program or clinic.
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Heals-medical-dental-optometry-enrollment-form is a form used to enroll in medical, dental, and optometry services provided by HEALS.
Any individual seeking to enroll in medical, dental, or optometry services through HEALS is required to file heals-medical-dental-optometry-enrollment-form.
To fill out heals-medical-dental-optometry-enrollment-form, you need to provide personal information, medical history, insurance details, and sign the form.
The purpose of heals-medical-dental-optometry-enrollment-form is to gather necessary information from individuals seeking medical, dental, or optometry services through HEALS for enrollment purposes.
On heals-medical-dental-optometry-enrollment-form, you must report personal details, contact information, medical history, insurance information, and any specific healthcare needs.
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