Chipped or injured primary or permanent teeth?
Please list any other physicians you seePhysician Name 1 City, State 1 Reason 1 Physician Name 2 City, State 2Reason 2
Please list any medication, nutritional supplement, herbal medication or non-prescription medicines, including fluoride supplements that you take.Medication 1 taken for Reason 1Medication 2 taken for Reason 2 Medication 3 taken for Reason 3 Medication 4 taken for Reason 4 Medication 5 taken for Reason 5Medication 6 taken for Reason 6Medication 7 taken for Reason 7Medication 8 taken for Reason 8