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What is the purpose of your visit today : _____________________________________________________________________________________________ Have you had any problems with past dental treatment? Yes No If yes, please explain : ___________________________________________________________________________________________________________ If Yes, Which one? ____________________________ Membership No. : ______________________________ Ref No : ___________________________ No Card No. :_________________________________ How did you hear about this practice? _______________________ To whom shal we make your accounts payable? ____________________________ I have read and understand Beyond Smiles Privacy Policy. I understand that payment is required on the day of treatment.
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Name of your general Medical Doctor : _________________________________________ Phone : __________________________________________ Address : ___________________________________________________________________________________________________________________ Are you being treated for a medical condition at present? ____________________________________________________________________________ Are you taking any medications or supplements at present, both prescribed or over the counter? (Please List) __________________________________________________________________________________________________________________________ Do you have, or have you ever had, any of the following medical conditions?
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Assessing the Potential Value of Rare Metals in Urban Mines: A Comparative Look at Korea and Japan By JUNG Ho-Sung Co-authored by KIM Hwa-Nyeon and CHOI Myeong-Hae September 2011 I. The Rise of Rare Metals Rare metals refer to metals which are scarce in the earth’s crust, or which are scarce because they are difficult to extract and process. Rare metals are also met

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Medical Information Dowling Catholic High School Instrumental Music Department Student name: ___________________________________ Grade: _________ Birth date: ________________ Address: ________________________________________ Home phone: ______________________________ Parent/Guardian: ________________________________ Work phone: ___________ Cell phone: _________ Parent/Guar

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