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Dental history rate your oral health: ________________ contact information phone number (home): Excellent good fair poor date of last dental visit: I certify that i have read and understand the above and that the information given on this form is accurate. The document is available in both english and spanish;
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J As Required By Law, Our Office Adheres To Written Policies And Procedures To Protect The Privacy Of Information About You That We Create, Receive Or Maintain.
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