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Emailed
Please Take Xrays
Does this patient take blood thinners Coumadin or Plavix
04/17/2026Click to Sign
please contact patient to schedule
patietent is scheduled on checkbox
patient will call practice to schedule
Extractions
Dental Implants
Wisdom TeethConsultation
Pathology
Impacted
Fully Erupted
other
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Patient Carrying
Mailed
X-ray attached
Does the patient require antibiotic prophylaxis prior to dental procedures
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