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Address Do You have Dual Coverage Group No. plan local or policy Insurance Phone No. General Information School Brothers/Sisters include ages DISTRICT Hobbies Medical History Medical Physician Phone Is the child currently under the care of a physician Has puberty begun Yes No If Yes explain Has menstruation period begun N/A What are the main concerns that you would like orthodontics to accomplish Has the patient ever been evaluated for orthodontic treatment Have the patient s tonsils or...

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