Child's Information
First Parent's Information
  • United States+1
  • United Kingdom+44
  • Afghanistan (افغانستان‎)+93
  • Albania (Shqipëri)+355
  • Algeria (الجزائر‎)+213
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  • Bangladesh (বাংলাদেশ)+880
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  • Belize+501
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  • Bosnia and Herzegovina (Босна и Херцеговина)+387
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  • Cambodia (កម្ពុជា)+855
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  • Dominican Republic (República Dominicana)+1
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  • El Salvador+503
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  • Gambia+220
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  • Kyrgyzstan (Кыргызстан)+996
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  • North Korea (조선 민주주의 인민 공화국)+850
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  • Philippines+63
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  • Portugal+351
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  • Russia (Россия)+7
  • Rwanda+250
  • Saint Barthélemy (Saint-Barthélemy)+590
  • Saint Helena+290
  • Saint Kitts and Nevis+1869
  • Saint Lucia+1758
  • Saint Martin (Saint-Martin (partie française))+590
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  • Sint Maarten+1721
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  • Switzerland (Schweiz)+41
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  • Taiwan (台灣)+886
  • Tajikistan+992
  • Tanzania+255
  • Thailand (ไทย)+66
  • Timor-Leste+670
  • Togo+228
  • Tokelau+690
  • Tonga+676
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  • Tunisia (تونس‎)+216
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  • Turkmenistan+993
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  • United States+1
  • Uruguay+598
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  • Vatican City (Città del Vaticano)+39
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  • United States+1
  • United Kingdom+44
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  • Anguilla+1264
  • Antigua and Barbuda+1268
  • Argentina+54
  • Armenia (Հայաստան)+374
  • Aruba+297
  • Australia+61
  • Austria (Österreich)+43
  • Azerbaijan (Azərbaycan)+994
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  • Belize+501
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  • Cambodia (កម្ពុជា)+855
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  • Canada+1
  • Cape Verde (Kabu Verdi)+238
  • Caribbean Netherlands+599
  • Cayman Islands+1345
  • Central African Republic (République centrafricaine)+236
  • Chad (Tchad)+235
  • Chile+56
  • China (中国)+86
  • Colombia+57
  • Comoros (جزر القمر‎)+269
  • Congo (DRC) (Jamhuri ya Kidemokrasia ya Kongo)+243
  • Congo (Republic) (Congo-Brazzaville)+242
  • Cook Islands+682
  • Costa Rica+506
  • Côte d’Ivoire+225
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  • Denmark (Danmark)+45
  • Djibouti+253
  • Dominica+1767
  • Dominican Republic (República Dominicana)+1
  • Ecuador+593
  • Egypt (مصر‎)+20
  • El Salvador+503
  • Equatorial Guinea (Guinea Ecuatorial)+240
  • Eritrea+291
  • Estonia (Eesti)+372
  • Ethiopia+251
  • Falkland Islands (Islas Malvinas)+500
  • Faroe Islands (Føroyar)+298
  • Fiji+679
  • Finland (Suomi)+358
  • France+33
  • French Guiana (Guyane française)+594
  • French Polynesia (Polynésie française)+689
  • Gabon+241
  • Gambia+220
  • Georgia (საქართველო)+995
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  • Gibraltar+350
  • Greece (Ελλάδα)+30
  • Greenland (Kalaallit Nunaat)+299
  • Grenada+1473
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  • Guam+1671
  • Guatemala+502
  • Guinea (Guinée)+224
  • Guinea-Bissau (Guiné Bissau)+245
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  • Haiti+509
  • Honduras+504
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  • Iran (ایران‎)+98
  • Iraq (العراق‎)+964
  • Ireland+353
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  • Italy (Italia)+39
  • Jamaica+1876
  • Japan (日本)+81
  • Jordan (الأردن‎)+962
  • Kazakhstan (Казахстан)+7
  • Kenya+254
  • Kiribati+686
  • Kuwait (الكويت‎)+965
  • Kyrgyzstan (Кыргызстан)+996
  • Laos (ລາວ)+856
  • Latvia (Latvija)+371
  • Lebanon (لبنان‎)+961
  • Lesotho+266
  • Liberia+231
  • Libya (ليبيا‎)+218
  • Liechtenstein+423
  • Lithuania (Lietuva)+370
  • Luxembourg+352
  • Macau (澳門)+853
  • Macedonia (FYROM) (Македонија)+389
  • Madagascar (Madagasikara)+261
  • Malawi+265
  • Malaysia+60
  • Maldives+960
  • Mali+223
  • Malta+356
  • Marshall Islands+692
  • Martinique+596
  • Mauritania (موريتانيا‎)+222
  • Mauritius (Moris)+230
  • Mexico (México)+52
  • Micronesia+691
  • Moldova (Republica Moldova)+373
  • Monaco+377
  • Mongolia (Монгол)+976
  • Montenegro (Crna Gora)+382
  • Montserrat+1664
  • Morocco (المغرب‎)+212
  • Mozambique (Moçambique)+258
  • Myanmar (Burma) (မြန်မာ)+95
  • Namibia (Namibië)+264
  • Nauru+674
  • Nepal (नेपाल)+977
  • Netherlands (Nederland)+31
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  • Nicaragua+505
  • Niger (Nijar)+227
  • Nigeria+234
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  • Philippines+63
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  • Portugal+351
  • Puerto Rico+1
  • Qatar (قطر‎)+974
  • Réunion (La Réunion)+262
  • Romania (România)+40
  • Russia (Россия)+7
  • Rwanda+250
  • Saint Barthélemy (Saint-Barthélemy)+590
  • Saint Helena+290
  • Saint Kitts and Nevis+1869
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  • Saint Martin (Saint-Martin (partie française))+590
  • Saint Pierre and Miquelon (Saint-Pierre-et-Miquelon)+508
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  • Sint Maarten+1721
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  • Solomon Islands+677
  • Somalia (Soomaaliya)+252
  • South Africa+27
  • South Korea (대한민국)+82
  • South Sudan (جنوب السودان‎)+211
  • Spain (España)+34
  • Sri Lanka (ශ්‍රී ලංකාව)+94
  • Sudan (السودان‎)+249
  • Suriname+597
  • Swaziland+268
  • Sweden (Sverige)+46
  • Switzerland (Schweiz)+41
  • Syria (سوريا‎)+963
  • Taiwan (台灣)+886
  • Tajikistan+992
  • Tanzania+255
  • Thailand (ไทย)+66
  • Timor-Leste+670
  • Togo+228
  • Tokelau+690
  • Tonga+676
  • Trinidad and Tobago+1868
  • Tunisia (تونس‎)+216
  • Turkey (Türkiye)+90
  • Turkmenistan+993
  • Turks and Caicos Islands+1649
  • Tuvalu+688
  • U.S. Virgin Islands+1340
  • Uganda+256
  • Ukraine (Україна)+380
  • United Arab Emirates (الإمارات العربية المتحدة‎)+971
  • United Kingdom+44
  • United States+1
  • Uruguay+598
  • Uzbekistan (Oʻzbekiston)+998
  • Vanuatu+678
  • Vatican City (Città del Vaticano)+39
  • Venezuela+58
  • Vietnam (Việt Nam)+84
  • Wallis and Futuna+681
  • Yemen (اليمن‎)+967
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  • Zimbabwe+263
  • United States+1
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  • Algeria (الجزائر‎)+213
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  • Andorra+376
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  • Armenia (Հայաստան)+374
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  • Australia+61
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  • Cook Islands+682
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  • Dominican Republic (República Dominicana)+1
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  • Egypt (مصر‎)+20
  • El Salvador+503
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  • Grenada+1473
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  • Guam+1671
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  • Guinea (Guinée)+224
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  • Guyana+592
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  • Iraq (العراق‎)+964
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  • Jamaica+1876
  • Japan (日本)+81
  • Jordan (الأردن‎)+962
  • Kazakhstan (Казахстан)+7
  • Kenya+254
  • Kiribati+686
  • Kuwait (الكويت‎)+965
  • Kyrgyzstan (Кыргызстан)+996
  • Laos (ລາວ)+856
  • Latvia (Latvija)+371
  • Lebanon (لبنان‎)+961
  • Lesotho+266
  • Liberia+231
  • Libya (ليبيا‎)+218
  • Liechtenstein+423
  • Lithuania (Lietuva)+370
  • Luxembourg+352
  • Macau (澳門)+853
  • Macedonia (FYROM) (Македонија)+389
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  • Malawi+265
  • Malaysia+60
  • Maldives+960
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  • Malta+356
  • Marshall Islands+692
  • Martinique+596
  • Mauritania (موريتانيا‎)+222
  • Mauritius (Moris)+230
  • Mexico (México)+52
  • Micronesia+691
  • Moldova (Republica Moldova)+373
  • Monaco+377
  • Mongolia (Монгол)+976
  • Montenegro (Crna Gora)+382
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  • Morocco (المغرب‎)+212
  • Mozambique (Moçambique)+258
  • Myanmar (Burma) (မြန်မာ)+95
  • Namibia (Namibië)+264
  • Nauru+674
  • Nepal (नेपाल)+977
  • Netherlands (Nederland)+31
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  • Nigeria+234
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  • Norfolk Island+672
  • North Korea (조선 민주주의 인민 공화국)+850
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  • Oman (عُمان‎)+968
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  • Palau+680
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  • Philippines+63
  • Poland (Polska)+48
  • Portugal+351
  • Puerto Rico+1
  • Qatar (قطر‎)+974
  • Réunion (La Réunion)+262
  • Romania (România)+40
  • Russia (Россия)+7
  • Rwanda+250
  • Saint Barthélemy (Saint-Barthélemy)+590
  • Saint Helena+290
  • Saint Kitts and Nevis+1869
  • Saint Lucia+1758
  • Saint Martin (Saint-Martin (partie française))+590
  • Saint Pierre and Miquelon (Saint-Pierre-et-Miquelon)+508
  • Saint Vincent and the Grenadines+1784
  • Samoa+685
  • San Marino+378
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  • Senegal (Sénégal)+221
  • Serbia (Србија)+381
  • Seychelles+248
  • Sierra Leone+232
  • Singapore+65
  • Sint Maarten+1721
  • Slovakia (Slovensko)+421
  • Slovenia (Slovenija)+386
  • Solomon Islands+677
  • Somalia (Soomaaliya)+252
  • South Africa+27
  • South Korea (대한민국)+82
  • South Sudan (جنوب السودان‎)+211
  • Spain (España)+34
  • Sri Lanka (ශ්‍රී ලංකාව)+94
  • Sudan (السودان‎)+249
  • Suriname+597
  • Swaziland+268
  • Sweden (Sverige)+46
  • Switzerland (Schweiz)+41
  • Syria (سوريا‎)+963
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  • Tajikistan+992
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Second Parent's Information
  • United States+1
  • United Kingdom+44
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First Parent's Dental Insurance Information
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  • Niue+683
  • Norfolk Island+672
  • North Korea (조선 민주주의 인민 공화국)+850
  • Northern Mariana Islands+1670
  • Norway (Norge)+47
  • Oman (عُمان‎)+968
  • Pakistan (پاکستان‎)+92
  • Palau+680
  • Palestine (فلسطين‎)+970
  • Panama (Panamá)+507
  • Papua New Guinea+675
  • Paraguay+595
  • Peru (Perú)+51
  • Philippines+63
  • Poland (Polska)+48
  • Portugal+351
  • Puerto Rico+1
  • Qatar (قطر‎)+974
  • Réunion (La Réunion)+262
  • Romania (România)+40
  • Russia (Россия)+7
  • Rwanda+250
  • Saint Barthélemy (Saint-Barthélemy)+590
  • Saint Helena+290
  • Saint Kitts and Nevis+1869
  • Saint Lucia+1758
  • Saint Martin (Saint-Martin (partie française))+590
  • Saint Pierre and Miquelon (Saint-Pierre-et-Miquelon)+508
  • Saint Vincent and the Grenadines+1784
  • Samoa+685
  • San Marino+378
  • São Tomé and Príncipe (São Tomé e Príncipe)+239
  • Saudi Arabia (المملكة العربية السعودية‎)+966
  • Senegal (Sénégal)+221
  • Serbia (Србија)+381
  • Seychelles+248
  • Sierra Leone+232
  • Singapore+65
  • Sint Maarten+1721
  • Slovakia (Slovensko)+421
  • Slovenia (Slovenija)+386
  • Solomon Islands+677
  • Somalia (Soomaaliya)+252
  • South Africa+27
  • South Korea (대한민국)+82
  • South Sudan (جنوب السودان‎)+211
  • Spain (España)+34
  • Sri Lanka (ශ්‍රී ලංකාව)+94
  • Sudan (السودان‎)+249
  • Suriname+597
  • Swaziland+268
  • Sweden (Sverige)+46
  • Switzerland (Schweiz)+41
  • Syria (سوريا‎)+963
  • Taiwan (台灣)+886
  • Tajikistan+992
  • Tanzania+255
  • Thailand (ไทย)+66
  • Timor-Leste+670
  • Togo+228
  • Tokelau+690
  • Tonga+676
  • Trinidad and Tobago+1868
  • Tunisia (تونس‎)+216
  • Turkey (Türkiye)+90
  • Turkmenistan+993
  • Turks and Caicos Islands+1649
  • Tuvalu+688
  • U.S. Virgin Islands+1340
  • Uganda+256
  • Ukraine (Україна)+380
  • United Arab Emirates (الإمارات العربية المتحدة‎)+971
  • United Kingdom+44
  • United States+1
  • Uruguay+598
  • Uzbekistan (Oʻzbekiston)+998
  • Vanuatu+678
  • Vatican City (Città del Vaticano)+39
  • Venezuela+58
  • Vietnam (Việt Nam)+84
  • Wallis and Futuna+681
  • Yemen (اليمن‎)+967
  • Zambia+260
  • Zimbabwe+263
Second Parent's Dental Insurance Information
  • United States+1
  • United Kingdom+44
  • Afghanistan (افغانستان‎)+93
  • Albania (Shqipëri)+355
  • Algeria (الجزائر‎)+213
  • American Samoa+1684
  • Andorra+376
  • Angola+244
  • Anguilla+1264
  • Antigua and Barbuda+1268
  • Argentina+54
  • Armenia (Հայաստան)+374
  • Aruba+297
  • Australia+61
  • Austria (Österreich)+43
  • Azerbaijan (Azərbaycan)+994
  • Bahamas+1242
  • Bahrain (البحرين‎)+973
  • Bangladesh (বাংলাদেশ)+880
  • Barbados+1246
  • Belarus (Беларусь)+375
  • Belgium (België)+32
  • Belize+501
  • Benin (Bénin)+229
  • Bermuda+1441
  • Bhutan (འབྲུག)+975
  • Bolivia+591
  • Bosnia and Herzegovina (Босна и Херцеговина)+387
  • Botswana+267
  • Brazil (Brasil)+55
  • British Indian Ocean Territory+246
  • British Virgin Islands+1284
  • Brunei+673
  • Bulgaria (България)+359
  • Burkina Faso+226
  • Burundi (Uburundi)+257
  • Cambodia (កម្ពុជា)+855
  • Cameroon (Cameroun)+237
  • Canada+1
  • Cape Verde (Kabu Verdi)+238
  • Caribbean Netherlands+599
  • Cayman Islands+1345
  • Central African Republic (République centrafricaine)+236
  • Chad (Tchad)+235
  • Chile+56
  • China (中国)+86
  • Colombia+57
  • Comoros (جزر القمر‎)+269
  • Congo (DRC) (Jamhuri ya Kidemokrasia ya Kongo)+243
  • Congo (Republic) (Congo-Brazzaville)+242
  • Cook Islands+682
  • Costa Rica+506
  • Côte d’Ivoire+225
  • Croatia (Hrvatska)+385
  • Cuba+53
  • Curaçao+599
  • Cyprus (Κύπρος)+357
  • Czech Republic (Česká republika)+420
  • Denmark (Danmark)+45
  • Djibouti+253
  • Dominica+1767
  • Dominican Republic (República Dominicana)+1
  • Ecuador+593
  • Egypt (مصر‎)+20
  • El Salvador+503
  • Equatorial Guinea (Guinea Ecuatorial)+240
  • Eritrea+291
  • Estonia (Eesti)+372
  • Ethiopia+251
  • Falkland Islands (Islas Malvinas)+500
  • Faroe Islands (Føroyar)+298
  • Fiji+679
  • Finland (Suomi)+358
  • France+33
  • French Guiana (Guyane française)+594
  • French Polynesia (Polynésie française)+689
  • Gabon+241
  • Gambia+220
  • Georgia (საქართველო)+995
  • Germany (Deutschland)+49
  • Ghana (Gaana)+233
  • Gibraltar+350
  • Greece (Ελλάδα)+30
  • Greenland (Kalaallit Nunaat)+299
  • Grenada+1473
  • Guadeloupe+590
  • Guam+1671
  • Guatemala+502
  • Guinea (Guinée)+224
  • Guinea-Bissau (Guiné Bissau)+245
  • Guyana+592
  • Haiti+509
  • Honduras+504
  • Hong Kong (香港)+852
  • Hungary (Magyarország)+36
  • Iceland (Ísland)+354
  • India (भारत)+91
  • Indonesia+62
  • Iran (ایران‎)+98
  • Iraq (العراق‎)+964
  • Ireland+353
  • Israel (ישראל‎)+972
  • Italy (Italia)+39
  • Jamaica+1876
  • Japan (日本)+81
  • Jordan (الأردن‎)+962
  • Kazakhstan (Казахстан)+7
  • Kenya+254
  • Kiribati+686
  • Kuwait (الكويت‎)+965
  • Kyrgyzstan (Кыргызстан)+996
  • Laos (ລາວ)+856
  • Latvia (Latvija)+371
  • Lebanon (لبنان‎)+961
  • Lesotho+266
  • Liberia+231
  • Libya (ليبيا‎)+218
  • Liechtenstein+423
  • Lithuania (Lietuva)+370
  • Luxembourg+352
  • Macau (澳門)+853
  • Macedonia (FYROM) (Македонија)+389
  • Madagascar (Madagasikara)+261
  • Malawi+265
  • Malaysia+60
  • Maldives+960
  • Mali+223
  • Malta+356
  • Marshall Islands+692
  • Martinique+596
  • Mauritania (موريتانيا‎)+222
  • Mauritius (Moris)+230
  • Mexico (México)+52
  • Micronesia+691
  • Moldova (Republica Moldova)+373
  • Monaco+377
  • Mongolia (Монгол)+976
  • Montenegro (Crna Gora)+382
  • Montserrat+1664
  • Morocco (المغرب‎)+212
  • Mozambique (Moçambique)+258
  • Myanmar (Burma) (မြန်မာ)+95
  • Namibia (Namibië)+264
  • Nauru+674
  • Nepal (नेपाल)+977
  • Netherlands (Nederland)+31
  • New Caledonia (Nouvelle-Calédonie)+687
  • New Zealand+64
  • Nicaragua+505
  • Niger (Nijar)+227
  • Nigeria+234
  • Niue+683
  • Norfolk Island+672
  • North Korea (조선 민주주의 인민 공화국)+850
  • Northern Mariana Islands+1670
  • Norway (Norge)+47
  • Oman (عُمان‎)+968
  • Pakistan (پاکستان‎)+92
  • Palau+680
  • Palestine (فلسطين‎)+970
  • Panama (Panamá)+507
  • Papua New Guinea+675
  • Paraguay+595
  • Peru (Perú)+51
  • Philippines+63
  • Poland (Polska)+48
  • Portugal+351
  • Puerto Rico+1
  • Qatar (قطر‎)+974
  • Réunion (La Réunion)+262
  • Romania (România)+40
  • Russia (Россия)+7
  • Rwanda+250
  • Saint Barthélemy (Saint-Barthélemy)+590
  • Saint Helena+290
  • Saint Kitts and Nevis+1869
  • Saint Lucia+1758
  • Saint Martin (Saint-Martin (partie française))+590
  • Saint Pierre and Miquelon (Saint-Pierre-et-Miquelon)+508
  • Saint Vincent and the Grenadines+1784
  • Samoa+685
  • San Marino+378
  • São Tomé and Príncipe (São Tomé e Príncipe)+239
  • Saudi Arabia (المملكة العربية السعودية‎)+966
  • Senegal (Sénégal)+221
  • Serbia (Србија)+381
  • Seychelles+248
  • Sierra Leone+232
  • Singapore+65
  • Sint Maarten+1721
  • Slovakia (Slovensko)+421
  • Slovenia (Slovenija)+386
  • Solomon Islands+677
  • Somalia (Soomaaliya)+252
  • South Africa+27
  • South Korea (대한민국)+82
  • South Sudan (جنوب السودان‎)+211
  • Spain (España)+34
  • Sri Lanka (ශ්‍රී ලංකාව)+94
  • Sudan (السودان‎)+249
  • Suriname+597
  • Swaziland+268
  • Sweden (Sverige)+46
  • Switzerland (Schweiz)+41
  • Syria (سوريا‎)+963
  • Taiwan (台灣)+886
  • Tajikistan+992
  • Tanzania+255
  • Thailand (ไทย)+66
  • Timor-Leste+670
  • Togo+228
  • Tokelau+690
  • Tonga+676
  • Trinidad and Tobago+1868
  • Tunisia (تونس‎)+216
  • Turkey (Türkiye)+90
  • Turkmenistan+993
  • Turks and Caicos Islands+1649
  • Tuvalu+688
  • U.S. Virgin Islands+1340
  • Uganda+256
  • Ukraine (Україна)+380
  • United Arab Emirates (الإمارات العربية المتحدة‎)+971
  • United Kingdom+44
  • United States+1
  • Uruguay+598
  • Uzbekistan (Oʻzbekiston)+998
  • Vanuatu+678
  • Vatican City (Città del Vaticano)+39
  • Venezuela+58
  • Vietnam (Việt Nam)+84
  • Wallis and Futuna+681
  • Yemen (اليمن‎)+967
  • Zambia+260
  • Zimbabwe+263
Assignment of Benefits

Assignment of Benefits: I hereby authorize payment directly to the above named dentists of the group dental benefits otherwise payable to me but not to exceed the charges shown on the claim. I understand that I am financially responsible for 100% of all charges and any charges not covered by this authorization.

All balances past due 60 days are subject to a finance charge of 1.5% per month (an annual rate of 18%) and/or subject to all legal and collection expenses.

Medical Information
  • United States+1
  • United Kingdom+44
  • Afghanistan (افغانستان‎)+93
  • Albania (Shqipëri)+355
  • Algeria (الجزائر‎)+213
  • American Samoa+1684
  • Andorra+376
  • Angola+244
  • Anguilla+1264
  • Antigua and Barbuda+1268
  • Argentina+54
  • Armenia (Հայաստան)+374
  • Aruba+297
  • Australia+61
  • Austria (Österreich)+43
  • Azerbaijan (Azərbaycan)+994
  • Bahamas+1242
  • Bahrain (البحرين‎)+973
  • Bangladesh (বাংলাদেশ)+880
  • Barbados+1246
  • Belarus (Беларусь)+375
  • Belgium (België)+32
  • Belize+501
  • Benin (Bénin)+229
  • Bermuda+1441
  • Bhutan (འབྲུག)+975
  • Bolivia+591
  • Bosnia and Herzegovina (Босна и Херцеговина)+387
  • Botswana+267
  • Brazil (Brasil)+55
  • British Indian Ocean Territory+246
  • British Virgin Islands+1284
  • Brunei+673
  • Bulgaria (България)+359
  • Burkina Faso+226
  • Burundi (Uburundi)+257
  • Cambodia (កម្ពុជា)+855
  • Cameroon (Cameroun)+237
  • Canada+1
  • Cape Verde (Kabu Verdi)+238
  • Caribbean Netherlands+599
  • Cayman Islands+1345
  • Central African Republic (République centrafricaine)+236
  • Chad (Tchad)+235
  • Chile+56
  • China (中国)+86
  • Colombia+57
  • Comoros (جزر القمر‎)+269
  • Congo (DRC) (Jamhuri ya Kidemokrasia ya Kongo)+243
  • Congo (Republic) (Congo-Brazzaville)+242
  • Cook Islands+682
  • Costa Rica+506
  • Côte d’Ivoire+225
  • Croatia (Hrvatska)+385
  • Cuba+53
  • Curaçao+599
  • Cyprus (Κύπρος)+357
  • Czech Republic (Česká republika)+420
  • Denmark (Danmark)+45
  • Djibouti+253
  • Dominica+1767
  • Dominican Republic (República Dominicana)+1
  • Ecuador+593
  • Egypt (مصر‎)+20
  • El Salvador+503
  • Equatorial Guinea (Guinea Ecuatorial)+240
  • Eritrea+291
  • Estonia (Eesti)+372
  • Ethiopia+251
  • Falkland Islands (Islas Malvinas)+500
  • Faroe Islands (Føroyar)+298
  • Fiji+679
  • Finland (Suomi)+358
  • France+33
  • French Guiana (Guyane française)+594
  • French Polynesia (Polynésie française)+689
  • Gabon+241
  • Gambia+220
  • Georgia (საქართველო)+995
  • Germany (Deutschland)+49
  • Ghana (Gaana)+233
  • Gibraltar+350
  • Greece (Ελλάδα)+30
  • Greenland (Kalaallit Nunaat)+299
  • Grenada+1473
  • Guadeloupe+590
  • Guam+1671
  • Guatemala+502
  • Guinea (Guinée)+224
  • Guinea-Bissau (Guiné Bissau)+245
  • Guyana+592
  • Haiti+509
  • Honduras+504
  • Hong Kong (香港)+852
  • Hungary (Magyarország)+36
  • Iceland (Ísland)+354
  • India (भारत)+91
  • Indonesia+62
  • Iran (ایران‎)+98
  • Iraq (العراق‎)+964
  • Ireland+353
  • Israel (ישראל‎)+972
  • Italy (Italia)+39
  • Jamaica+1876
  • Japan (日本)+81
  • Jordan (الأردن‎)+962
  • Kazakhstan (Казахстан)+7
  • Kenya+254
  • Kiribati+686
  • Kuwait (الكويت‎)+965
  • Kyrgyzstan (Кыргызстан)+996
  • Laos (ລາວ)+856
  • Latvia (Latvija)+371
  • Lebanon (لبنان‎)+961
  • Lesotho+266
  • Liberia+231
  • Libya (ليبيا‎)+218
  • Liechtenstein+423
  • Lithuania (Lietuva)+370
  • Luxembourg+352
  • Macau (澳門)+853
  • Macedonia (FYROM) (Македонија)+389
  • Madagascar (Madagasikara)+261
  • Malawi+265
  • Malaysia+60
  • Maldives+960
  • Mali+223
  • Malta+356
  • Marshall Islands+692
  • Martinique+596
  • Mauritania (موريتانيا‎)+222
  • Mauritius (Moris)+230
  • Mexico (México)+52
  • Micronesia+691
  • Moldova (Republica Moldova)+373
  • Monaco+377
  • Mongolia (Монгол)+976
  • Montenegro (Crna Gora)+382
  • Montserrat+1664
  • Morocco (المغرب‎)+212
  • Mozambique (Moçambique)+258
  • Myanmar (Burma) (မြန်မာ)+95
  • Namibia (Namibië)+264
  • Nauru+674
  • Nepal (नेपाल)+977
  • Netherlands (Nederland)+31
  • New Caledonia (Nouvelle-Calédonie)+687
  • New Zealand+64
  • Nicaragua+505
  • Niger (Nijar)+227
  • Nigeria+234
  • Niue+683
  • Norfolk Island+672
  • North Korea (조선 민주주의 인민 공화국)+850
  • Northern Mariana Islands+1670
  • Norway (Norge)+47
  • Oman (عُمان‎)+968
  • Pakistan (پاکستان‎)+92
  • Palau+680
  • Palestine (فلسطين‎)+970
  • Panama (Panamá)+507
  • Papua New Guinea+675
  • Paraguay+595
  • Peru (Perú)+51
  • Philippines+63
  • Poland (Polska)+48
  • Portugal+351
  • Puerto Rico+1
  • Qatar (قطر‎)+974
  • Réunion (La Réunion)+262
  • Romania (România)+40
  • Russia (Россия)+7
  • Rwanda+250
  • Saint Barthélemy (Saint-Barthélemy)+590
  • Saint Helena+290
  • Saint Kitts and Nevis+1869
  • Saint Lucia+1758
  • Saint Martin (Saint-Martin (partie française))+590
  • Saint Pierre and Miquelon (Saint-Pierre-et-Miquelon)+508
  • Saint Vincent and the Grenadines+1784
  • Samoa+685
  • San Marino+378
  • São Tomé and Príncipe (São Tomé e Príncipe)+239
  • Saudi Arabia (المملكة العربية السعودية‎)+966
  • Senegal (Sénégal)+221
  • Serbia (Србија)+381
  • Seychelles+248
  • Sierra Leone+232
  • Singapore+65
  • Sint Maarten+1721
  • Slovakia (Slovensko)+421
  • Slovenia (Slovenija)+386
  • Solomon Islands+677
  • Somalia (Soomaaliya)+252
  • South Africa+27
  • South Korea (대한민국)+82
  • South Sudan (جنوب السودان‎)+211
  • Spain (España)+34
  • Sri Lanka (ශ්‍රී ලංකාව)+94
  • Sudan (السودان‎)+249
  • Suriname+597
  • Swaziland+268
  • Sweden (Sverige)+46
  • Switzerland (Schweiz)+41
  • Syria (سوريا‎)+963
  • Taiwan (台灣)+886
  • Tajikistan+992
  • Tanzania+255
  • Thailand (ไทย)+66
  • Timor-Leste+670
  • Togo+228
  • Tokelau+690
  • Tonga+676
  • Trinidad and Tobago+1868
  • Tunisia (تونس‎)+216
  • Turkey (Türkiye)+90
  • Turkmenistan+993
  • Turks and Caicos Islands+1649
  • Tuvalu+688
  • U.S. Virgin Islands+1340
  • Uganda+256
  • Ukraine (Україна)+380
  • United Arab Emirates (الإمارات العربية المتحدة‎)+971
  • United Kingdom+44
  • United States+1
  • Uruguay+598
  • Uzbekistan (Oʻzbekiston)+998
  • Vanuatu+678
  • Vatican City (Città del Vaticano)+39
  • Venezuela+58
  • Vietnam (Việt Nam)+84
  • Wallis and Futuna+681
  • Yemen (اليمن‎)+967
  • Zambia+260
  • Zimbabwe+263
Dental Information

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my child’s health. It is my responsibility to inform the dental office of any changes in my child’s medical status. I also authorize the dental staff to perform the necessary dental services that my child may need. I also authorize the dentist to release any information including the diagnosis and the records of the treatment or examination rendered to my child during the period of such care to third party payers and/or other health practitioners. I further acknowledge the receipt of the Dental Materials Fact Sheet dated October 2001 and HIPPA Privacy Form.

Verification