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  • ABCD Dental Referral

    Tacoma-Pierce County Health Department is committed to protecting the confidentiality of your medical information, and the law requires us to do so. Read the complete Notice of Privacy Practices.

    Asterisk (*)- Required field.

    Child Information

    Child Name(Required)
    MM slash DD slash YYYY
    Gender

    Family Information

    Parent/Guardian Name(Required)
    Address

    Additional Children

    Child 1 – Name
    MM slash DD slash YYYY
    Child 2 – Name
    MM slash DD slash YYYY
    Child 3 – Name
    MM slash DD slash YYYY

    Referring Agency