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Patient Name: DOB: Chart Number: I hereby request and authorize: Lake Superior Community Health Center 4325 Grand Ave Duluth, MN 55807 Dental Fax: 2186246594 Dental Phone: 2186287035 Medical Fax:
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Begin filling out the form by entering your personal information, such as your name, address, and contact details. Make sure to provide accurate and up-to-date information.
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Continue by providing the necessary details related to the dental procedure or treatment for which you are seeking return on investment. This may include the name of the procedure, the date it was performed, and the amount paid or invested.
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Remember, it is always advisable to consult with the relevant dental professionals or organizations regarding any specific requirements or guidelines for filling out the ROI form-dentalpdf.
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