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  • Welcome to our office. We appreciate the confidence you place with us to provide dental services. To assist us in serving you, please complete the following form. The information provided on this form is important to your dental health. If there have been any changes in your health, please tell us. If you have any questions, don’t hesitate to ask.

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  • DENTAL HEALTH HISTORY

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  •  MEDICAL HEALTH HISTORY

    Do you have, or have you had, any of the following?

  • Do you have any disease, condition, or problem not listed previously that you feel we should know about?

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  • Should be Empty: