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Com 891 Kuhn Drive Suite 205 Chula Vista California 91914 Right to Revoke You will have the right to revoke this Consent at any time by giving us written notice of your revocation submitted to the Contact Person listed above. Valeria Poggio DDS MS 891 Kuhn Dr Ste 205 Chula Vista CA 91914 Tel. 619 482-2412 Fax 619 482-2442 CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION SECTION A PATIENT GIVING CONSENT Responsible Party Name Address Telephone Home Work/Cell Patient s Name SECTION B TO THE...
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Valeria Poggio DDS MS is a dental practice owned by Valeria Poggio offering dental services and specialized treatments.
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