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Peoria, IL Periodontist - Christopher Couri, DDS, MS ...Dental History Name of General Dentist: Last visit date: Date of last dental x-rays: Reason for visit: Date of last teeth cleaning:

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Page 1: Peoria, IL Periodontist - Christopher Couri, DDS, MS ...Dental History Name of General Dentist: Last visit date: Date of last dental x-rays: Reason for visit: Date of last teeth cleaning:

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