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Description of Medical Necessity
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Too Much Work (required more than 2-30 min appointments)
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Description:
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Previous Traumatic Experience with Doctors/Dentists
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Description:
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Too young to cooperate with examinations/xrays
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Description:
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Previous Failed Treatment Attempts
• • •
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Description:
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Special Needs/Cognitive Limitations
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Description:
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Other:
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Signature/Affirmation: (Type Name)
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