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Does the patient require Prophylactic Antibiotic Coverage prior to dental treatment Yes No If no please state reason Oral Regimen you recommend RX DISP SIG 2. Hidy Stavarache of Hidy Stavarache D. D. S. Ltd. I hereby authorize Hidy Stavarache D. D. S. Ltd. to receive and use my protected medical information for the purpose of documenting any and all medical clearance required prior to dental treatment. Hidy Stavarache D. D. S. 9910 W. Cheyenne Avenue Suite 170 Las Vegas Nevada 89129 702...
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