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  • Other family members seen by us?

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  • Parent Information

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  • Person Responsible For Account

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  • Medical and Dental History

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  • Are You Allergic To Any Of The Following?

  • Did / Do your child have any of the following habits?

  • Have you ever had any of the following medical problems?

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36150 Dequindre Rd Suite 800, Sterling Heights, MI 48310
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