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Photo Submission Form
"
*
" indicates required fields
Your Name
First
Last
Doctor's Name
*
First
Last
Check the box if this doctor is also a board member
DLN Board Member
Patient's Name
*
First
Last
State
*
Attach Photo #1
Max. file size: 50 MB.
Please provide names of all people in photo #1, including other staff members or family members.
Attach Photo #2
Max. file size: 50 MB.
Please provide names of all people in photo #2, including other staff members or family members.
Attach Photo #3
Max. file size: 50 MB.
Please provide names of all people in photo #3, including other staff members or family members.
Other Information
Please provide any back ground or story information from either the patient or doctor or other associated person.
Attach photo consent form
Max. file size: 50 MB.
You can find this on the last page of the patient application. Please provide this if it is signed.
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Dental Lifeline Network
1800 15th Street, Suite 100
Denver, CO 80202
Phone: 303.534.5360
Fax: 303.534.5290
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