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Dental History

Please answer all the questions carefully. This information is confidential.
Have you ever had: (Check if yes )
Are you allergic to any of these?
To the best of my knowledge, the above-information is accurate and true. If the patient is a minor, I, as the parent/guardian, give my permission for any needed dental treatment.
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(205) 980-8777
4647 Hwy 280 Suite E, Birmingham, AL 35242
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