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Gilmore DMD. If monthly payments are necessary I accept the terms and conditions as disclosed on the Financial Policy. Yes I know that a credit report will be generated for any extension of credit. Signature Date MEDICAL HISTORY Name of medical doctor Date of last examination Are you under a physicians care Yes No Women Only Are you pregnant Yes No If yes what is your due date Are you on any blood thinners Aspirin Warfin etc. Yes No If yes what is your INR/PT Do you take or have you taken...
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