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Medical History Form
Dental Vue
1443 Lee Street
Des Plaines IL 60018
Phone: 847-294-0404 Fax: 1-847-376-3587
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Patient Information
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Please rank the following in the order in which they would KEEP YOU FROM having dental treatment: (with "1" being least likely to keep you from having treatment and "5" being very likely)
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Date of last full mouth x-rays: