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First Name

Last Name

Date Of Birth

Phone

Do you have a chronic treatment? If yes, what medicine are you using and when?

Do you have allergies for cetain medicine? If yes, specify.

Do you have a particular illness? If yes, specify.

Do you smoke? If yes, how much?

Do you consume alcohol? If yes, how much?

Do you have any moving teeth? If yes, which one(s)?

Pictures of your dentition and panoramic radio (Obligatory)

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