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Medical History Update

Modern Care Dental

3927 W. Belmont Ave, Suite 105,
Chicago, IL 60618
(773) 481-2090

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Medical History Update( * mandatory to fill )
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  •  If there has been no change in your health since your last dental appointment, please Initial here

NOTE: EVEN IF THERE HAS BEEN NO CHANGE IN YOUR HEALTH HISTORY PLEASE SIGN AND DATE THIS FORM.

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