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Eeded to determine your dental health as part of the family member relocation clearance for travel. If you are enrolled in the TRICARE Dental Plan, your civilian dentist completes this form. If you are not enrolled in the TRICARE Dental Plan, your military dental treatment facility completes this form. 1a. PATIENT NAME (Last, First, Middle Initial) b. SPONSOR SSN c. FAMILY MEMBER PREFIX 2. DENTAL EXAMINATION RESULTS Dear Doctor, The individual you are examining is a family member of an active.

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