Jason Hong DDS & Kathy Lam DDS PC logo Commitment to Safety

<p> &lt;p&gt; &amp;lt;h1&amp;gt;School Form Requests&amp;lt;/h1&amp;gt; &amp;lt;form method=&amp;quot;post&amp;quot; name=&amp;quot;contactForm&amp;quot; action=&amp;quot;assets/php/tntforms.php&amp;quot;&amp;gt; &amp;lt;input type=&amp;quot;hidden&amp;quot; value=&amp;quot;../../thank-you.html&amp;quot; name=&amp;quot;redirect&amp;quot; /&amp;gt; &amp;lt;input type=&amp;quot;hidden&amp;quot; name=&amp;quot;env_report&amp;quot; value=&amp;quot;REMOTE_HOST,HTTP_USER_AGENT&amp;quot; /&amp;gt; &amp;lt;div style=&amp;quot;margin-bottom: 3px;&amp;quot;&amp;gt;Your Name:&amp;lt;/div&amp;gt; &amp;lt;input type=&amp;quot;text&amp;quot; style=&amp;quot;margin-bottom: 5px;&amp;quot; name=&amp;quot;parent name&amp;quot; value=&amp;quot;&amp;quot; /&amp;gt; &amp;lt;div style=&amp;quot;margin-bottom: 3px;&amp;quot;&amp;gt;Your Child&amp;#39;s Name:&amp;lt;/div&amp;gt; &amp;lt;input type=&amp;quot;text&amp;quot; style=&amp;quot;margin-bottom: 5px;&amp;quot; name=&amp;quot;child name&amp;quot; value=&amp;quot;&amp;quot; /&amp;gt; &amp;lt;div style=&amp;quot;margin-bottom: 3px;&amp;quot;&amp;gt;Would you like me to email or fax the form back to you?&amp;lt;/div&amp;gt; Email:&amp;lt;input type=&amp;quot;radio&amp;quot; value=&amp;quot;email form&amp;quot; name=&amp;quot;how to send&amp;quot; /&amp;gt; Fax: &amp;lt;input type=&amp;quot;radio&amp;quot; value=&amp;quot;fax form&amp;quot; name=&amp;quot;how to send&amp;quot; /&amp;gt; &amp;lt;p&amp;gt;&amp;amp;nbsp;&amp;lt;/p&amp;gt; &amp;lt;div style=&amp;quot;margin-bottom: 3px;&amp;quot;&amp;gt;Your Email/Fax:&amp;lt;/div&amp;gt; &amp;lt;input type=&amp;quot;text&amp;quot; style=&amp;quot;margin-bottom: 5px;&amp;quot; name=&amp;quot;email/fax&amp;quot; value=&amp;quot;&amp;quot; /&amp;gt; &amp;lt;div style=&amp;quot;margin-bottom: 3px;&amp;quot;&amp;gt;Please Verify Code:&amp;lt;/div&amp;gt; &amp;lt;img alt=&quot;&quot; src=&amp;quot;assets/php/CaptchaSecurityImages.php?width=100&amp;amp;amp;height=40&amp;amp;amp;characters=5&amp;quot; /&amp;gt;&amp;lt;br /&amp;gt; &amp;lt;input type=&amp;quot;text&amp;quot; id=&amp;quot;security_code&amp;quot; name=&amp;quot;security_code&amp;quot; value=&amp;quot;type image above&amp;quot; onclick=&amp;quot;if(this.value==&amp;#39;type image above&amp;#39;){this.value=&amp;#39;;}&amp;quot; /&amp;gt; &amp;lt;br /&amp;gt; &amp;lt;input type=&amp;quot;submit&amp;quot; value=&amp;quot;Submit&amp;quot; /&amp;gt; &amp;lt;input type=&amp;quot;hidden&amp;quot; value=&amp;quot;child form requests&amp;quot; name=&amp;quot;subject&amp;quot; /&amp;gt; &amp;lt;/form&amp;gt; &amp;lt;p&amp;gt;Requests will be fulfilled within 48 hours. In order to qualify, exams must be current and have been completed within the last 6 months.&amp;lt;a href=&amp;quot;assets/docs/IL-School-Dental-Exam-requirements.pdf&amp;quot; target=&amp;quot;_blank&amp;quot;&amp;gt;&amp;lt;br /&amp;gt; &amp;lt;/a&amp;gt;&amp;lt;/p&amp;gt;&lt;/p&gt;</p>

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