15DC2770_Clinical Forms_173-196 2/13/15 10:32 AM Page 191 Patient Information & Registration Forms A Adult B Adult C Child CLINICAL FORMS 366-1152 Front 367-5010 Back Front 366-5845 Back Front Back A-C. ADULT & CHILD REGISTRATION FORMS * 2-sided forms warmly welcome patients to your office * Complete with California requirement Phen-Fen/Redux Adult...........................................................................250 per Pkg. 2 Pkg.@ 5 Pkg.@ 55.99 52.99 45.99 Child ..........................................................................100 per Pkg. 3 Pkg.@ 5 Pkg.@ 42.99 38.99 35.99 Imprinted Materials: 800.414.0940 8am-4:30pm (ET) Call To Order: 800.372.4346 8am-9pm (ET) 191http://www.henryschein.com/redirect.aspx?did=dental&returnurl=/us-en/Shopping/ProductDetails.aspx%3Fproductid%3D3665845%26CatalogName%3DDENTAL http://www.henryschein.com/redirect.aspx?did=dental&returnurl=/us-en/Shopping/ProductDetails.aspx%3Fproductid%3D3661152%26CatalogName%3DDENTAL http://www.henryschein.com/redirect.aspx?did=dental&returnurl=/us-en/Shopping/ProductDetails.aspx%3Fproductid%3D3675010%26CatalogName%3DDENTAL