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Matthew S. Dear DDS, MSD Diplomat, American Board of Endodontics Preeti Basra BDS, MSD Specialist in EndodonticsDATE ___ / ___ / ___ PATIENTS NAME ___ REFERRED BY DR. ___ Please mark teeth to be treated.1 2 3 4 5 6 7 89 10111213141516 ___ R32 31 30 29 28 27 26 2524 23 22 21 20 19 18 17LTREATMENT

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