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By the Financial Conduct Authority. Registered Office: The St Botolph Building, 138 Houndsditch, London EC3A 7AW. Registered in England No. 01524095. VAT No. 244 2321 96 Page 2 Claim Form Dental claims This section may only be completed by a dentist who is trained, qualified, and licensed to practice dentistry by the licencing authority of the country in which you receive treatment. 21) Please provide the dental history for the last 12 months? If this is a claim for restorative treatment a.

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