"Ignore your teeth, they'll go away".

    "You don't have to brush all your teeth, just the one's you want to keep".

 

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          Dr. Michael Robinson

                 Fellow in Academy of General Dentistry

                           McIntosh, Alabama  

            
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Alabama Dental Association

 

 

 

  "REDNECK PACIFIER"

Patient Information

 
  • Patient

First Name: Middle:

 Last Name: male female

Date of Birth:  YEAR

Street Address: 

Mailing Address:

City:    State:  Zip:

Telephone:  Home 

                     Work: ext

                  Cellular:  

E-mail:

 

  • Responsible Party/Parent (If Patient is a minor)

First Name:    Middle:   

Last Name: 

Street Address: 

Mailing Address: 

City:    State: Zip:

Telephone:  Work: ext

Cellular:   E-mail:

 

  • Employment

Company: 

  Address: 

City:  State: Zip:

                                                              

 


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No representation is made that the quality of dental services to be provided is superior to the quality of services provided by other dentists.

Send mail to drmike@docktormike.com with questions or comments about this web site.
Copyright © 2002 R. Michael Robinson D.M.D.
Last modified: November 17, 2003