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Last Dental Visit & Where
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Have You Had Any Serious Trouble Associated With Any Previous Dental Treatment
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Habit History
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Medical History
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Do You Suffer From? (Please Put Tick)
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ARTHRITIS OR PAIN IN JAW JOINTS
PARKINSONS DISEASE
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Declaration
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I, hereby declare that the above mentioned statements are true to the best of my knowledge and belief. And I authorize THE PULP RCTS & IMPLANTS to use it for the clinical purpose.
I, the undersigned, voluntarily consent to participate in an online consultation with The Pulp Dental Care. I understand that the consultation is not a substitute for an in-person evaluation. I consent to the collection and secure storage of my personal and medical information for the purpose of this consultation. I acknowledge that I have read, understood, and agree to the terms and conditions of this online consultation. *
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