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I am responsible for anything that my prophylaxis/fluoride treatment. If my insurance does not cover it that often it is my responsibility to let the staff know before my child s appointment. I have read and understand the above policy and agree to abide by this policy. Patient legal guardian or authorized agent of patient Patients name Parent or Guardian name Relationship to patient Consent to proceed I authorize Dr Jared D Pearson D. 00 deposit that will be refunded to me within a week...

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