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Page 1: DENTAL REGISTRATION AND HISTORY C] NO PATIENT … · DENTAL HISTORY Reason for today's visit Former Dentist City/State Date of last dental visit Date of last dental X-rays Relationship

Page 2: DENTAL REGISTRATION AND HISTORY C] NO PATIENT … · DENTAL HISTORY Reason for today's visit Former Dentist City/State Date of last dental visit Date of last dental X-rays Relationship

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Dr. Daniel Stegall€¦ · Notes 5. DENTAL HISTORY Reason for today's visit Former Dentist Last Cleaning State Email Date Fax: 972.499.7740 Please Continue to 2nd Page Signature Last

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: Analysis of Telephone Survey 2014. · iv Table 28: Estimated population proportion (95% Cl) of respondents reporting last visit to a dental professional by LGA, Central Coast, CHS

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