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This includes but is not limited to examinations orthodontic care dental cleanings fluoride treatments x-rays and restorative care. He or she also has my authorization to make any decision based on Dr. Derek Busciglio and his associate s recommendation s regarding treatment in my absence. I agree to assume financial responsibility for his/her decisions. I also give permission for those named above to have any Ortho/ Dental treatment/Medical History reviewed and discussed. This consent is...
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