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IF THIS CONSENT IS SIGNED BY A PERSONAL REPRESENTATIVE ON BEHALF OF THE PATIENT COMPLETE THE FOLLOWING PERSONAL REPRESENTATIVE NAME RELATIONSHIP TO PATIENT Signature Date YOU ARE ENTITLED TO A COPY OF THIS CONSENT AFTER YOU SIGN IT Authorization/Request for Dental Images Please forward the most recent x-rays even if not current and/or records as soon as possible to WelcomeToPDG PrairieDental.com Signature Phone Number City/State/Zip Code Previous Dentist Phone Fax For Office Use Date Called...
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