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Appointment Inquiry Form
Confirmed prenatal exposure to alcohol?
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No
Unknown
What is the requested appointment for? Select all that apply.
Technical Assistance
Training
Diagnostic Evaluation
Personal Consultation
What type of insurance does the patient have?
Arkansas Medicaid
Other Insurance in Arkansas (Blue Cross Blue Sheild, Cigna, Aetna, Humana, or similar)
Tricare
Insurance from a state outside of Arkansas
Unknown
No Insurance
Other
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