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Kirkpatrick & Lai
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A family business for over 50 Years
Tulsa
(918) 747-1346
Tahlequah
(918) 458-5050
Miami
(918) 542-1867
Okmulgee
(918) 756-5070
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Our Story
Media
Invisalign
Testimonials
Giving Back
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FAQ
Emergency
Contact Us
Locations
Tulsa
(918) 747-1346
Tahlequah
(918) 458-5050
Miami
(918) 542-1867
Okmulgee
(918) 756-5070
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*
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*
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*
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*
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Prefers to be called
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*
MM slash DD slash YYYY
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*
Hidden
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Father's Full Name
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Do you have contact information for the patient's mother/wife?
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No
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Mother's Full Name
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Title
Mrs.
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Street Address
Address Line 2
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Northern Mariana Islands
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Puerto Rico
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Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
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Wisconsin
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Armed Forces Americas
Armed Forces Europe
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State
ZIP Code
School/Employer
Grade/Position
Email Address
Home Phone
Cell Phone
Work Phone
Hidden
Siblings: Name & Age
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Siblings: Name & Age
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Siblings: Name & Age
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How did you hear about our office?
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Responsible Party Email
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Patient Email (If Over 18)
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Responsible Party Full Name
*
First
Last
Relation to Patient
*
Address
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Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
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Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Best Contact Phone #
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Cell Phone
Do you have dental insurance?
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(if yes, please ask for additional insurance form)
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Is the patient on SoonerCare?
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(only applies if under the age of 18)
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I certify the above information is true and correct to the best of my knowledge.
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