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Get UK Miller & Isaacs Cleeve Dental Confidential Medical History Form 2012-2024

Uk Web: www.cleevedental.co.uk CONFIDENTIAL MEDICAL HISTORY FORM Title: First Name: Date of Birth: Surname: If child, Parent/Guardian's name: Address: Postcode: Telephone: (Home) (Work) (Fax) (Email) Occupation: (Mobile) Medical Practitioner & Practice: PLEASE ANSWER EVERY QUESTION AND CIRCLE CORRECT ANSWER 1. Are you allergic to ? 2. Have you ever had RHEUMATIC FEVER or been told you have a HEART MURMUR? 3. Do you have a LATEX allergy? 4. Do you take or an.

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