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Medical History Form

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In order to render optimum dental service, it is necessary to become acquainted with the vital information related to each patient. All information
is strictly confidential and although some questions may seem unimportant at the moment, they may become vital in the case of an emergency.

Patient Information

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Medical History

Have You Had Major Surgery? If so, Please Describe

Dental

Dental Insurance

Primary Dental Plan

Secondary Dental Plan

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