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