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MEDICAL HISTORY WELCOME So that we may provide you with the best possible care please complete this medial/dental history form. All information is completely confidential. PATIENT NAME MEDICAL ALERTS REASON FOR TODAY S VISIT WHEN WERE DENTAL XRAYS LAST TAKEN Has there been any problem with your general health within the past year Yes No If so what was the problem Are you under a physician s care now Yes No If so for what Physician s name Phone Have you ever been hospitalized for any serious...
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