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Kevin Avert, D.D.S., F.R.C.D.© Oral and Maxillofacial SurgeonPatient Name: ___Date: ___Referred By: ___ Consultation IV or N2O Sedation b c d e Extraction8 7 6 5 4 3 2 11 2 3 4 5 6 7 8 Pathology

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