Medical Release For Dental Treatment Form
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___ this patient is optimized for surgery and. Contact information for the patient’s primary health care. Please sign and fax form to: Web teeth, fractured teeth or fillings, loose teeth or other oral pathology and no anticipation of dental care within the next 6 months. The patient’s health conditions and illnesses.
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_____, Certify That I Am The Parent Or Legal Guardian Of The Minor Listed Below, And As Such, I Hereby Convey.
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