Appointment Request Form v5

Patient Information
If applicable, enter your Member Number below.
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DOB Code Check
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The member number is incomplete or does not match our records. Please remember that all letters must be capitalized. Contact your employer if this message is in error.
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Discount pediatric clinic visits are only available to patients under the age of 18.
Date of birth does not match our records. Member discount has not been applied. Please contact your employer if this message is in error.
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Welcome {firstName}, your member discount has been applied!
Bienvenido {firstName}, se ha aplicado su descuento de miembro.
DOB Check
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First Name Import
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Last Name*
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Are you a new patient?*

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Parent / Guardian*

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Text Opt In

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*These messages could include information regarding purchases, deliveries, events, and general information about our products and services. Message frequency varies. Text HELP to 226466 or email info@camino.org for help, STOP to 226466 to end. Msg & Data Rates May Apply. By opting in, I authorize Camino Community Development to deliver marketing messages using an automatic telephone dialing system and I understand that I am not required to opt in as a condition of purchasing any property, goods, or services.

Click to view Terms and Conditions and Privacy Policy
*Estos mensajes pueden incluir información sobre compras, entregas, eventos e información general sobre nuestros productos y servicios. La frecuencia de los mensajes varía. Envía AYUDA al 226466 o escribe a info@camino.org para recibir ayuda, o envía ALTO al 226466 para detener los mensajes. Pueden aplicarse tarifas de mensajes y datos. Al aceptar, autorizo a Camino Community Development a enviar mensajes de marketing utilizando un sistema automático de marcación telefónica y entiendo que no se requiere que acepte como condición para comprar ninguna propiedad, bien o servicio.

Haz clic para ver los Términos y Condiciones y la Política de Privacidad

Schedule Your Appointment
An office visit fee of ${number} is due at the time of service.
Se debe pagar una tarifa de ${number} por la visita al consultorio en el momento del servicio.
The Comprehensive Oral Examination includes a full dental exam, intraoral x-rays, and a panoramic x-ray to provide a complete understanding of your oral health. We’ll use the results to guide next steps in your dental care (go to CaminoSalud.com to see our pricing for additional services).
El Examen Oral Integral incluye una evaluación dental completa, radiografías intraorales y una radiografía panorámica para obtener una comprensión total de tu salud bucal. Usaremos los resultados para guiar los siguientes pasos en tu cuidado dental (visita CaminoSalud.com para ver nuestros precios de servicios adicionales).

Terms
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Credit Card Details
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Credit Card Number	Security Code
Card Expiration

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Concertar una cita

Appointment Selection

Claudia Telemedicine

Patient Information

New Patient Information

Schedule Your Appointment