Please fill out the form below before your appointment.  We prefer you send us the electronic form; however, you can also print the form at home and bring to your appointment.  Just hit the print link at the bottom.  Please note that fields marked with a red asterisk are required to be filled out.  Please hit the submit button at the bottom to send your form to us electronically.  This form is protected and HIPAA compliant.

Make Your Smile an Audubon Smile!

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716 Second Street, Henderson KY    (270) 827-5222