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Printable Form 966 Pembroke Pines Florida: What You Should Know

All applicants must have a Current Florida Drivers Licensing Number (i.e., Florida Driver's License or Florida identification card) on file and may be contacted directly by the hospital before the actual procedure. If your license has been suspended, and you need to have it reinstated before your dental appointment, you must contact the DMV at or. 2. You must be prepared to provide the date (MM/DD/YYY) and time of your oral surgery in order for us to know the procedure date. 3. You will need to complete an application for Form D&E 762 (Dental and Related Facilities Examination), which can be downloaded here. 4. All applicants will need to have one picture taken by the Hospital. When you are ready to begin the application, you must complete two applications. 5. We require a copy of the entire application and a copy of your current Florida driver's license or Florida identification. We will need an original or two copies of an FFL license. 6. Your initial payment will be 95, which will be credited back onto your dental charge at the time of filing. Additional charges may apply, and any insurance premiums and/or co-insurance will be billed and applied during the procedure. We accept: MasterCard, Discover and American Express. A second payment will be required upon completion. If you would like a copy of the D&E 762 or are having an expedited procedure, you will need to fill out a copy of the online Form 966 (or a copy of the D&E 762). You will need to pay the 95 initial fee when your deposit is credited back. This means that if you need more than one appointment, you will need to submit the additional payment for each additional appointment. You will need a minimum of: 1. Two Color photographs. 2. Application.  3. Payment if your dental charges exceed 500.  Please call the office for the current processing and processing times to make an appointment. If you have any questions regarding your dental clinic or procedures, please call the front desk at. You can also e-mail us at (NOTE: A fax is welcome. Do not use this phone number.

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