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Danya Mermelstein D. M. D. Ronen Krausz D. D. S. Roger Taylor D. M. D. 1560 Beacon Street Brookline MA 02446 T 617 -731-5437 www. Pediatric Adolescent Dentistry and Orthodontics Arnold I. Weiss D. D. S. Wesley T. Barton D. M. D. I retain the responsibility for all charges by The Center for Pediatric Dental Care LLC resulting from from any liability arising from this form and Designated Adult s consent to or refusal of treatment for I understand that the Privacy Rule of the Health Insurance...
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