FOR OFFICE USE ONLY - Family Dentistry | Summit Dental …

Headaches, jaw joint pain. Broken teeth or broken fillings. Grinding or clenching teeth. Bleeding, swollen, or sore gums. Do you smoke or use chewing tobacco? Y N. How Much? _____For how long? _____ If I could change my smile, I would: Make them whiter. Make them straighter or close spaces. Repair chipped teeth. Replace missing teeth ................
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