St
Concordia Learning Center at St. Joseph’s School for the Blind
761 Summit Ave., Jersey City, NJ 07307
(201) 876-5432/ Fax (201) 876-5430
Dental Examination
Name of Student____________________________ Date____________________
Dear Doctor,
Your patient attends Concordia Learning Center at St. Joseph’s School for the Blind. Please complete the following:
This certifies that I have examined the above named student and:
___ All necessary dental work is completed.
___ Treatment is in progress.
Further recommendations include:
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|Dentist’s Signature | |Date |
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|Dentist’s Printed Name | | |
|Dentist’s Address: | |
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|Phone Number: | |
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