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Get ADA Health History Form - Gantz Dental

Ceive or maintain. Your answers are for our records only and will be kept confidential subject to applicable laws. Please note that you will be asked some questions about your responses to this questionnaire and there may be additional questions concerning your health. This information is vital to allow us to provide appropriate care for you. This office does not use this information to discriminate. Name: Home Phone: Last First ( Middle Address: Business/Cell Phone: Include area code ).

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