INTRODUCING: *
AGE: *
PARENT / GUARDIAN NAME: *
LAST PROPHY:
LAST EXAM:
LAST FLUORIDE TREATMENT:
LAST X-RAYS:
X-RAY DELIVERY:
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PLEASE INDICATE THE PROBLEM AREAS IN THE FIELD BELOW: *
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REFERRING DOCTOR: *
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WE ARE REFERRING THE PATIENT ABOVE FOR THE FOLLOWING REASON(S):
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