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Yes No Do you now or have you ever in your life had any of the following Heart Condition Rheumatic Fever Diabetes Hepatitis Epilepsy AIDS Blood Transfusions Psychological or Emotional Problems Headaches Frequent Bleeding Tendencies Tuberculosis Lupus or Other. JOSEPH Y. DE JESUS D. D. S. P. S. 344 Cleveland Ave. Suite D Tumwater WA 98501 360 943-4531 Date PATIENT INFORMATION Home Address City Age Birthdate School Grade Family Dentist Referred by RESPONSIBLE PARTY INFORMATION FATHER Phone...
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