Patient Information

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Have you ever been a patient in our practice?
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Has a family member ever been a patient in our practice?:
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How would you like to be contacted?
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Referred By
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YOUR ADDRESS
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Birthdate
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Age
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Gender
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Relationship Status
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SPOUSE INFORMATION OR OTHER GUARANTOR INFORMATION
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Spouse/Guarantor Birthdate
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EMPLOYER
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EMERGENCY CONTACT
Specify someone who does not live in your household
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Dental History

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Are you in pain?:
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Select "yes" or "no" to indicate if you have had any of the following:
Bad Breath
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Bleeding Gums
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Blisters on lip or mouth
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Burning sensation on tongue
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Chew on the side of mouth
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Cigarette, pipe or cigar smoking
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Clicking or popping jaw
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Dry mouth
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Fingernail biting
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Food collection between teeth
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Foreign objects
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Grinding teeth
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Gums swollen or tender
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Jaw pain or tiredness
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Lip or cheek biting
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Loose teeth or broken fillings
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Mouth breathing
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Mouth pain, brushing
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Orthodontic treatment
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Pain around the ear
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Periodontal Treatment
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Sensitive to cold
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Sensitive to heat
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Sensitive to sweets
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Sensitivity when biting
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Sores or growths in your mouth
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How often do you floss
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Health History

Physician's name
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Date of last visit
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Your Weight
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Your Height
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Are you in good health?
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Has a physician or previous dentist recommended antibiotic prophylaxis prior to your dental treatment?
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Have you had any illness, operation, or been hospitalized in the past five years?
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Select "yes" or "no" to indicate if you have had any of the following:
AIDS/HIV
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If yes, list viral load and CD4 count
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Anemia
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Arthritis, Rheumatism
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Artificial Heart Valves
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Artificial Joints
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Asthma
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Back Problems
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Bleeding abnormally, with extractions or surgery
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Blood Disease
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Cancer
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Chemical Dependency
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Chemotherapy
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Circulatory Problems
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Congenital Heart Lesions
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Cortisone Treatments
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Cough, persistent or bloody
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Diabetes
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If yes, list A1C
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Emphysema
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Do you wear contact lenses?
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Epilepsy
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Fainting or dizziness
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Glaucoma
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Headaches
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Heart Murmur
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Heart Problems
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Hepatitis
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Herpes
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High Blood Pressure
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Jaundice
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Jaw Pain
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Kidney Disease
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Last date of Dialysis
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Liver Disease
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Low Blood Pressure
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Mitral Valve Prolapse
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Nervous Problems
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Pacemaker
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Psychiatric Care
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Radiation Treatment
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Respiratory Disease
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Rheumatic Fever
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Scarlet Fever
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Shortness of Breath
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Sinus Trouble
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Skin Rash
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Special Diet
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Stroke
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Swollen Feet or Ankles
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Swollen Neck Glands
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Thyroid Problems
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Tonsillitis
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Tuberculosis
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Tumor or growth on head or neck
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Ulcer
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Venereal Disease
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Weight Loss, unexplained
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Women:

Women note: antibiotics (such as penicillin) may alter the effectiveness of birth control pills. Consult your physician/gynecologist for assistance regarding additional methods of birth control.
Taking birth control pills
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Are you nursing?
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Is there a possibility of pregnancy?
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If yes, expected delivery date:
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Medications & Allergies

MEDICATIONS
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Are you now taking:
Nerve Pills
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Diet Pills
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Pain Killers (Including Aspirin)
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Tranquilizers
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Muscle relaxers
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Insulin
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Stimulants
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Antidepressants
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Blood thinners (Coumadin,Aspirin)
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Are you taking, or have you ever taken, any bone density meds. or bisphosphonates, such as Fosamax, Boniva, Actonel, IV Zometa, Reclast, Xgeva, Prolia, or Aredia within the past 12 years?
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ALLERGIES - Select "yes" or "no" if you are allergic to or had a reaction to any of the following:
Amoxicillin
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Aspirin
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Barbiturates (Sleeping pills)
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Codeine or other narcotics:
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Eggs/Yolk
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Iodine
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Latex
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Local Anesthetic
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Penicillin
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Sodium pentothal /Valium/ other tranq.
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Soy
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Sulfa
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Sulfites
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List any other medication or antibiotic you are allergic to
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List any allergies other than drug allergies
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Primary Insurance Company

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  • Insurance Company State
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  • Massachusetts
  • Michigan
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  • Mississippi
  • Missouri
  • Montana
  • Nebraska
  • Nevada
  • New Hampshire
  • New Jersey
  • New Mexico
  • New York
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  • Ohio
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  • Subscriber's State
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I certify that I have read and I understand the questions above.

I acknowledge that my questions, if any, about the inquiries set forth above have been answered to my satisfaction. I will not hold my doctor, or any other member of his / her staff, responsible for any errors or omissions that I have made in the completion of this form.
Signature of patient (Parent or Guardian if Minor)
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Reviewed by:
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Today's Date
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FEES & PAYMENTS

We make every effort to keep down the cost of your care. You can help by paying upon completion of each visit. Other arrangements can be made with our office manager depending upon special circumstances. An estimate of the charge for any procedure or surgery you may require will be given to you upon request. If you have any dental and/or medical insurance we will be glad to fill out the proper forms, but please complete the identifying information on this form.

Please remember that insurance is considered a method of reimbursing the patient for fees paid to the doctor and is not a substitute for payment. Some companies pay fixed allowances for certain procedures and others pay a percentage of the charge. It is your responsibility to pay any deductible amount, co-insurance or any other balance not paid for by your insurance company. You will be responsible for all collection costs, attorneys fees, and court costs.

Signature of patient (Parent or Guardian if Minor)
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This signature on file is my authorization for the release of information necessary to process my claim. I hereby authorize payment to this doctor named of the benefits otherwise payable to me:
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NOTICE OF PRIVACY PRACTICES


NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION


PLEASE REVIEW IT CAREFULLY THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US



This Notice of Privacy Practices describes how we may use and disclose your protected health information to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. “Protected health information” is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services. We are required by law to maintain the privacy and security of your protected health information. We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information. We are required to abide by the terms of this Notice of Privacy Practices. We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind. We may change the terms of our notice, at any time. The new notice will be effective for all protected health information that we maintain at that time, as well as for any information we receive in the future. Upon your request, we will provide you with any revised Notice of Privacy Practices. You may request a revised version by accessing our website, or calling the office and requesting that a revised copy be sent to you in the mail or asking for one at the time of your next appointment.

USES AND DISCLOSURES OF HEALTH INFORMATION


We use and disclose health information about you for treatment, payment, and healthcare operations. For example:

Treatment: We may use or disclose your health information to a physician or other healthcare provider providing treatment to you, or to family and friends you approve.

Payment: We may use and disclose your health information to obtain payment for services we provide to you.

Healthcare Operations: We may use and disclose your health information in connection with our healthcare operations. Healthcare operations include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing or credentialing activities.

Your Authorization and Limitations: In addition to our use of your health information for treatment, payment or healthcare operations, you may give us written authorization to use your health information or to disclose it to anyone for any purpose. You also have the right to request restrictions on disclosure of PHI
(Personal Health Information), or alternative means of communication (e.g, home or business phone) to ensure privacy. We are not required to agree to all requests, and we may say “no” if it is not reasonable or would affect your care. If you pay for a service or item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your insurer. We will say “yes” unless a law requires us to share that information.

Marketing Health-Related Services: We will not use your health information for marketing communications or sell your health information without your written authorization.

Required by Law: We may use or disclose your health information when we are required to do so by law or national security activities.

Abuse or Neglect: We may disclose your health information to appropriate authorities when we suspect abuse or neglect.

Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders (such as voicemail messages, postcards, or letters).

PATIENT RIGHTS


Access: You have the right to look at or get electronic or paper copies of your health information with limited exceptions. If you request copies, we will charge you a reasonable fee to locate and copy your information, and postage if you want the copies mailed to you.

Amendment: You have the right to request that we amend your health information. We may say “no” to your request, but we’ll tell you why in writing.

Accounting: You can request a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with and why. We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable fee if you ask for another one within 12 months.

Representative: If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. We will make sure the person has this authority and can act for you before we take any action.

CANCELLATION POLICY


We do value your time, so we do not overbook appointments and increase wait times. For this reason, we require 24 hour notice for all cancellations. There will be a cancellation fee of $75 associated with all appointments broken without at least 24 hours of advance notice. Thank you for your trust in our practice”. But you can word it however you want to incorporate with the form. We just want them to know we need 24 hour notice.

QUESTIONS AND COMPLAINTS



If you want more information about our privacy practices or have questions or concerns, please contact us.

If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made about access to your health information or in response to a request you made to amend or restrict the use or disclosure of your health information or to have us communicate with you by alternative means or at alternative locations, you may complain to us using our EthicsPoint Help Line which is (888) 366-6034. You also may submit a written complaint to the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint with the U.S. Department of Health and Human Services upon request.

We support your right to the privacy of your health information. We will not retaliate in any way if you choose to file a complaint with us with the U.S. Department of Health and Human Services. A Privacy/Contact Officer has been designated for this office. The Privacy Officer can be contacted by simply contacting the office and asking to speak to the Office Manager who serves as the Privacy Officer.
I hereby acknowledge that a copy of this office's Notice of Privacy Practices has been made available to me. I have been given the opportunity to ask any questions I may have regarding this Notice.

Signature of patient (Parent or Guardian if Minor)
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