How did you hear about us? |
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Have you ever had any of the following diseases or medical problems |
Please list any serious medical condition(s) that you have ever had :
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Are you allergic to any of the following? |
Please list any other drugs / Materials that you are allergic to :
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Insurance information |
Primary insurance |
Dental history |
Why have you come to the dentist today?
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If not, what would you change?
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