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The above questions have been accurately an swered. I understand that providing incorrect information can be dan gerous to my child s health. SignaturelParent or Guaradian benefit plan. x Signature of Patient Parent or Guardian if Minor Date If for any reason I am unable to accompany my child to your office I grant my legal permission for the doctor and staff to render the treatment as. discussed with me to my child. Parent or Legal Guardian Sign.. e atur. charges for dental services and...
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