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PRIMARY DENTAL INSURANCE Apt State Zip Hobbies / Special Interests Siblings Ins. Name Ins. address Insurance Co. HEALTH HISTORY 8. DENTAL HISTORY Why did you bring this child to the Orthodontist today Has the child ever had a serious/difficult problem associated with dental work Is the child s water fluoridated Is the child taking fluoridated supplements the jaw joint TMJ/TMD Floss their teeth daily Does the child brush teeth daily Is the child currently under the care of a physician Heart...
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